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LIBRARY OF CONGRESS, 



UNITED STATES OF AMEEICA. 



EXPLORATION OF THE CHEST 
IN HEALTH AND DISEASE 




HEART. LUNGS, 



AND ARTERIES OF THE ; THORACIC CAVITY 
(BONAMY AND %EAU >. 



1, 2, left lung, divided into two lobes ; 3, 4. 5, right lung, divided into three 
lobes ; 6, right auricle ; 7, right ventricle ; 8, left ventricle ; 9, an- 
terior notch; 10, distribution of vessels upon the right ventricle; 
11, pericardium; 12, pulmonary artery; 13, aorta; 14, innominate 
artery; 15, right subclavian artery ; 16, left subclavian artery; 17, 
right common carotid artery ; 17 , left common carotid artery, 



EXPLORATION OF THE CHEST 
IN HEALTH AND DISEASE 



BY / 

STEPHEN SMITH BURT, M. D. 

PROFESSOR OF CLINICAL MEDICINE AND PHYSICAL DIAGNOSIS IN THE NEW 

YORK POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL | PHYSICIAN 

TO THE OUT-DOOR DEPARTMENT (DISEASES OF THE 

HEART AND LUNGS), BELLE YUE HOSPITAL 



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sf 




NEW YORK 
D . A P P L E T X AMD COMPANY 

1889 




.611 



Copyright, 1889, 
By D. APPLETON AND COMPANY. 



TO 

D. B. ST. JOHN ROOSA, M. D., LL. D., 

IN APPRECIATION OF HIS FRIENDSHIP, 

AND IN ADMIRATION FOR HIS MANY ATTAINMENTS, 

THIS BOOK IS INSCRIBED 

BY THE AUTHOR. 



PREFACE, 



Teaching naturally leads to requests from the 
class for a work that shall embody the methods pur- 
sued by the instructor. This present manual is the 
outcome of such requests. 

My object is to aid the student in his efforts to 
learn the significance of physical signs and their mode 
of development. 

In the construction of this book I have utilized 
the results of my own personal experience, as well as 
the common stock of medical teaching. I have made 
no attempt to establish pathognomonic or distinctive 
signs of disease, because it seems to me that pre- 
cision in diagnosis is more surely attained by treating 
each sign as subordinate to the various combinations 
of signs which are found in the different maladies. 



viii PEEFACE. 

I wish to emphasize the importance of knowing the 

physiological anatomy of the heart and lungs, the 

relative position of the viscera to the parietes, and the 

physical signs that can be developed in the normal 

chest, as upon such a foundation rests the only true 

basis for a correct understanding of the changes 

caused by disease. 

Stephen S. Burt, M. D. 

37 West Thirty-second Street, New York. 



CONTENTS. 



PAGE 

Introduction 7 

Explanation of the term physical signs ; Definition of ex- 
ploration ; Necessity for this method of examination ; Im- 
portance at the same time of subjective signs ; Reason for 
thoroughness ; Faults to be avoided ; Chest-marks ; Relative 
position of the lungs, liver, stomach, spleen, and kidneys to 
the surface of the chest described. 

Physical Methods of Diagnosis . . . . .17 
Six methods enumerated ; Calormetation or thermometry in 
place of succussion ; Essential aids to diagnosis ; Inspection ; 
Attitude, facial expression, and complexion in health and 
disease ; Deviations in the shape of the chest within physio- 
logical limits ; Changes in the contour of the thorax resulting 
from disease, and their significance ; Normal and abnormal 
movements of the chest; Inspection of the sputa as a means 
of diagnosis ; Membranous casts of the bronchi ; Rusty 
sputa ; Haemoptysis ; Bacillus tuberculosis ; Palpation ; 
Yocal fremitus ; Increased by consolidation, abolished by an 
effusion; Mensuration; Circumference and half-circumfer- 
ence of the chest as affected by disease. 

Calormetation 31 

Basis for the importance of measuring the temperature ; 
Normal heat of the body, and the influence of age and sex 
thereon ; Variations of temperature and their significance ; 
Mobility of temperature in children; Absence of febrile 



X CONTENTS. 

PAGE 

manifestations in old persons ; The thermometer and its 
manipulation ; Temperature in disease ; Bronchitis ; Pneu- 
monia; Pleurisy; Haemoptysis ; Acute miliary tuberculosis ; 
Chronic phthisis pulmonalis; Cancer of the lung; Asthma; 
Emphysema; (Edema; Endocarditis; Pericarditis; Chronic 
heart-disease ; Table of temperatures. 

Pekcussion 40 

Definition of percussion ; Forcible and gentle strokes ; Im- 
mediate and mediate percussion ; Plexor and pleximeter ; Posi- 
tion ; Manner of percussing ; Chief difficulty ; Acoustics ; 
Quality, pitch, intensity, and duration; Recapitulation; 
Resonance ; Types of resonance ; Key-note ; Regional per- 
cussion in health ; Resonance modified by age, sex, quantity 
of overlying tissue, and by respiration ; Auscultatory percus- 
sion ; Respiratory percussion ; Percussion in disease ; Rela- 
tive significance of a single sign ; Recapitulation. 

Auscultation ......... 58 

Reason for the value of auscultation ; Course to be pursued ; 
Immediate and mediate auscultation ; Necessity for the latter 
method of listening to the heart ; Stethoscopes ; An experi- 
ment that demonstrates the dual function of the ears ; Selec- 
tion and adjustment of the stethoscope, and suggestions in 
regard to its use ; Auscultatory signs in health ; Auscultatory 
signs in disease ; Mode of transmission of bronchial breath- 
ing; Recapitulation; Adventitious signs; Harsh breathing 
defined ; Sibilant and sonorous breathing ; Rhythm of sub- 
crepitant rales ; Gurgling rales ; Source of the crepitant 
rale ; Succussion ; Metallic tinkle ; Friction ; Extraneous 
sounds to be eliminated ; Recapitulation ; Vocal resonance ; 
Greater velocity of low-pitched tones ; Amphoric voice ; 
iEgophony ; Pectoriloquy ; Recapitulation. 

Diagnosis by Physical Signs of Diseases of the 

Lungs . . 82 

Importance of acquiring a knowledge of the general princi- 
ples of physical diagnosis; Acute catarrhal bronchitis; 



CONTEXTS. xi 



PAGE 



Chronic catarrhal bronchitis ; Summary, signs of bronchitis ; 
Bronchiectasis ; Acute capillary bronchitis ; Summary, signs 
of capillary bronchitis ; Croupous bronchitis ; Asthma ; Points 
of difference between laryngitis, oedema of the glottis, and 
asthma ; Summary, signs of asthma ; Haemoptysis ; Unjusti- 
fiable risk in disturbing the patient ; Pulmonary emphysema ; 
Summary, signs of emphysema ; Pulmonary oedema ; Sum- 
mary, signs of oedema. 

Pneumonia 98 

Seat and extension of the affection ; Termed single, double, 
and central, according to its locality ; Divided into three 
stages with respect to the physical signs ; First stage, con- 
gestion ; Rusty sputa ; Expectoration sometimes absent in 
children ; Temperature in pneumonia ; Temporary flights of 
the index; High fever in children; Critical conditions of 
old persons in pneumonia with little if any fever ; Crepitant 
rales overlooked ; Second stage, solidification ; Occasional 
absence of bronchial breathing due to feebleness of the 
respiration ; Bronchial puff ; Signs of pneumonia in very 
old persons often obscure ; Third stage, resolution ; Purulent 
infiltration; Abscess; Lobular pneumonia; Summary, signs 
of pneumonia. 

Pleurisy 106 

Fibrinous exudation ; Reason for the occasional absence of 
friction, and an expedient to favor its production; Differentia- 
tion of the first stage of pleurisy from the corresponding 
stage of pneumonia ; Serous effuson ; Absence of fremitus ; 
Low range of temperature ; Curvilinear flatness ; Sense of 
resistance to percussion-stroke ; Explanation of the cause of 
occasional vesiculotympanitic resonance above the fluid ; 
Acoustic law of sound-waves ; Bronchial breathing in pleurisy ; 
Value of listening in the axillary region ; J^gophony ; Active 
distinguished from passive effusion, and from consolidation ; 
Purulent effusion ; Aspirator ; Thoracentesis ; Absorption ; 
Points of difference between the signs of thick, plastic exuda- 



xii CONTENTS. 

PAGE 

tion and of fluid effusion ; Adhesions ; Summary, signs of 
subacute pleurisy, contrasted with those of pneumonia ; 
Hydrothorax ; Pneumothorax ; Pneumo-hydrothorax ; Pneu- 
mo-pyothorax ; Change in the level of flatness ; Succussion ; 
Summary, signs of air and fluid in pleural sac. 

Phthisis Pulmonalis 125 

Acute phthisis ; Chronic phthisis ; Divided into two stages ; 
First stage : The value of " myoidema " as a sign ; Caution 
about the early signs of phthisis ; Second stage : Various evi- 
dences of excavation, and where to look for them ; Summary, 
signs of chronic phthisis ; Acute miliary tuberculosis ; 
Fibroid phthisis or interstitial pneumonia ; Distinguishing 
feature, retraction of chest ; Sense of resistance on percus- 
sion ; Pulmonary gangrene ; Differentiated from fetid bron- 
chitis, and from phthisis with gangrenous odor ; Cancer of 
the Lung ; Points of difference between the flatness of a 
tumor and that of fluid effusion. 

EXPLORATION OF THE HEART ...... 140 

Location of the heart ; Kelativc position of its borders to the 
surface of the chest ; Superficial cardiac space ; Arteries ; 
Aorta ; Pulmonary artery ; Arteria innominata ; Site of valves ; 
Heart-sounds and where heard ; Sounds in contradistinction 
to murmurs ; Mechanism of the former ; Circulation of the 
blood through the heart ; Methods of examination ; Normal 
position of the apex ; Various causes for its displacement 
and the significance thereof ; Meaning of strong and of weak 
impulse ; Thermometry in cardiac disease ; Percussion ; 
Dullness and flatness of this organ ; Auscultation ; One 
cardiac revolution ; Analysis of heart-sounds ; Mapping the 
superficial space by vocal resonance ; Sounds modified by 
disease ; Accentuation of the pulmonary second sound. 

Heaet-Mukmurs 154 

Definition ; Cause demonstrated by an experiment ; Loud 
and soft murmurs ; Anaemic bruits ; Murmur accompanying 



CONTENTS. xiii 

PAGE 

a lesion the rule ; Result of valvular disease upon the cavi- 
ties of the heart ; Nature's compensation ; Danger-signal ; 
The quality of a murmur and its import ; Question presented ; 
Genesis of a bruit ; Effect of position and of medication upon 
a murmur; Impact of heart against the lung a source of 
error ; Systolic murmurs ; Possible bruits ; Determining a 
murmur; Anaemic bruit; A transient dynamic murmur; A 
temporary tricuspid bruit ; Murmurs that will disappear ; 
Diastolic murmurs ; Exceptions ; Presystolic murmurs ; The 
same in connection with aortic regurgitation; Pericardial 
friction; Associated murmurs ; Venous bruits ; Distinguished 
from arterial ; Hypothesis regarding the venous hum. 

Diagnosis by Physical Signs of Diseases of the Heaet 

and of Thoeacio Anetjeism 170 

Endocarditis ; Complications ; Ulcerative variety ; Curable 
murmurs ; Static and progressive lesions ; Pericarditis ; Dis- 
covered only by physical exploration ; Adhesions ; Signs 
elusive; Hydropericardium ; Cardiac hypertrophy; Dilata- 
tion of the heart ; Fatty degeneration of the heart ; Its 
bearing compared with valvular affections upon surgical 
anaesthesia ; Cheyne-Stokes respiration. 

Aoetio Stenosis 182 

Differentiation of the murmur of this organic lesion from 
functional bruits ; Aortic insufficiency ; The significance of 
Corrigan's pulse therein ; Mitral stenosis ; Mitral stenosis 
with insufficiency ; Useful hints for separating the two mur- 
murs of this lesion ; Commonly one murmur, and the reason ; 
Delay in the radial pulse ; Mitral insufficiency ; Effect of 
pulmonary emphysema upon the heart and its murmurs ; 
Tricuspid insufficiency ; Venous reflux ; Thoracic aneurism ; 
Location ; Expansive impulse ; Pressure signs and symptoms. 




LUNGS, ANTERIOR VIEW (SAPPEY). 

1, upper lobe of the left lung ; 2, lower lobe ; 3, fissure ; 4, notch correspond- 
ing to the apex of the heart ; 5, pericardium ; 6, upper lobe of the right 
lung; 7, middle lobe; 8, lower lobe; 9, fissure ; 10, fissure; 11, dia- 
phragm ; 12, anterior mediastinum; 13, thyroid gland ; 14, middle cer- 
vical aponeurosis ; 15, process of attachment of the mediastinum to the 
pericardium; 16, 16, seventh ribs; 17, 17, transversales muscles; 18, 
linea alba. 



EXPLOEATIO^ OF THE CHEST. 



INTEODUGtlON. 

The term physical signs, in medical parlance, re- 
fers to certain objective conditions of the body, as 
distinguished from what are commonly known as 
subjective signs or symptoms. 

Exploration is the careful examination of these 
physical signs in their manifestations of health as 
well as disease. From repeated observations of pa- 
tients, there was gradually evolved a system of signs, 
which bore a close relation to the condition of the 
organs as they were found upon post-mortem investi- 
gation. And, inasmuch as diseases of the chest have 
many symptoms in common, there is a manifest ne- 
cessity for this objective manner of procedure. But, 
though we shall dwell here more especially upon 
these methods, nevertheless, it must be kept in mind 
that the subjective signs hold a position of consider- 
able importance in the solving of medical problems. 



8 EXPLORATION OF THE CHEST. 

The sciences are but the development of common 
sense in special directions ; and the science of physi- 
cal diagnosis forms no exception to this rule. If the 
student will diligently apply himself to the principles 
involved in this subject, providing his senses are 
fairly acute, there is no good reason why he should 
not attain satisfactory proficiency therein. All exam- 
inations of the thorax should be exceedingly thor- 
ough and methodical, so that no part by any chance 
shaU escape attention. Each student should be hon- 
est with himself, and never claim to hear a sound 
when not certain that he does hear it as described 
to him. It is a matter of frequent remark, among 
those best able to judge, that some students are prone 
to acquiesce too readily in a diagnosis made for 
them. They are apt to hear whatever they are told 
to hear, and do not take the requisite trouble to posi- 
tively assure themselves. This is a fault, and should 
be avoided, as little real progress is made under such 
circumstances. 

It is well established that mental or nervous vibra- 
tions, which are at first the result of close and studied 
attention, ere long become facile and automatic by 
repetition. What is known as intuition is but the 
rapid action of an educated nervous system. A nov- 
ice, therefore, should not emulate an experienced ex- 



INTRODUCTION. 9 

aminer in this apparently easy process, for such emu- 
lation would soon resolve itself into the merest guess- 
work. On the contrary, he should endeavor to be 
slow and painstaking in the extreme. In fact, it is 
always better to submit to the tedium of methodical 
examination than ever to risk the danger of an erro- 
neous diagnosis. 

For the convenient reference of the student, the 
following description of the relation which the vis- 
cera bear to the surface of the body is given. And 
the outlines of these organs should be traced upon the 
chest of some available person in order to fix them in 
the memory. This is best done with one of those 
little cosmetic pencils that an actress employs in col- 
oring her eyelids, and which is obtainable at almost 
any shop where toilet articles are sold. 

In order to designate the position or extent of the 
various thoracic signs, some chest-marks are required, 
and the sternum, ribs, clavicles, and scapulae, together 
with a few artificial vertical lines, will adequately sup- 
ply this requirement. These lines are as follows — 
viz. : one falling from the middle of the clavicle to the 
free border of the ribs, known as the mammillary 
line ; one midway between this and the edge of the 
sternum, called the parasternal line ; one from the 
apex of the axilla, the axillary line ; and one from 



10 EXPLORATION OF THE CHEST. 

the lower angle of the scapula, termed the scapular 
line. 

Lungs. — The trachea, passing down behind the 
sternum, divides on a level with the second rib where 
the manubrium joins the gladiolus. To the right the 




Diagram illustrating the borders of the lung, liver, and stomach in 

front. 

main bronchus lies behind the second costal cartilage, 
to the left the main bronchus is a little below the car- 



INTRODUCTION. 11 

tilage. These subdivide into two branches before en- 
tering the lungs. 

The lung, in front, rises from one to one and three 
quarters of an inch above the clavicle, usually some- 
what higher on the right than the left side. The an- 
terior borders of this organ pass obliquely downward 
and inward across the sterno-clavicular articulation to 
the junction of the manubrium with the body of the 
sternum. From this point they are in contact down 
to the fourth rib. Here they separate. The right 
lung extends to the sixth intercostal space in the 
median line, where the lower border turns to 
the right along the cartilage of the sixth rib, and 
downward to the seventh rib in the axillary line, 
the tenth rib in the scapular line, and the eleventh 
rib between the scapular line and the vertebral 
column. 

The anterior border of the left lung turns to the 
left along the fourth costal cartilage as far as the para- 
sternal line, and thence down to the fifth costal carti- 
lage. Here it curves downward and inward to the 
sixth costal cartilage, and then again to the left, which 
leaves an open space for a portion of the heart and a 
tongue-like projection over the apex. The lower bor- 
der runs along the lower margin of the sixth rib, and 
down to the seventh rib in the axillary line, the tenth 



12 EXPLORATION OF THE CHEST. 

rib in the scapular line, and the eleventh rib between 
this and the vertebral column. 

The upper borders curve backward from the apices 
to the spine of the seventh cervical vertebra, while 




Diagram showing the right lower border of the lung, and liver. 

posteriorly the borders run dow r nward to the eleventh 
rib, one on each side of the vertebral column. 

The interlobular fissure on the left side extends 
from the lower border of the lung at the mammillary 



INTRODUCTION. 13 

line, upward and backward to the base of the spine 
of the left scapula. Upon the right side are two fis- 
sures, one from the lower border of the lung near 
the mammillary line, upward and backward to the 
base of the spine of the right scapula ; the other from 
the anterior border of the lung at the fourth costal 
cartilage, backward and slightly upward, joining the 
former a little above the inferior angle of the scapula. 

Liver. — A greater part of the liver lies upon the 
right side of the body, just beneath the diaphragm ; 
its left lobe extends about two inches to the left 
of the median line. 

The upper border corresponds to the arch of the 
diaphragm ; the lower border to the eleventh rib be- 
hind, the tenth intercostal space in the axillary line, 
and the tenth rib at the mammillary line ; whence 
it passes obliquely upward and inward from under 
the right costal arch, and crosses the median line, 
nearly three inches below the ensiform cartilage, to 
the left costal arch. 

The liver, at its highest point, reaches the fourth 
intercostal space, and its convex surface approaches 
sufficiently near the chest-wall to be demonstrable, 
by percussion, at the fifth rib in the right nipple line, 
and at about the fifth intercostal space in the right 
axillary line. 



14 EXPLORATION OF THE CHEST. 

Stomach. — The main part of the stomach is situ- 
ated in the left upper abdominal region. Its pyloric 
portion extends across the median line beneath the 
liver to the right costal arch. The upper surface rises 
to about the fifth rib in the left mammillary line. Its 




Diagram showing the spleen and the lower border of the left lung at 

the side. 

lower border or great curvature, passing downward 
and inward, emerges from the costal arch at the level 
of the tenth costal cartilage, and crosses the median 



INTRODUCTION. 



15 



line midway between the umbilicus and the ensiform 
cartilage. 

Although the stomach retains its location in the 
left upper portion of the abdomen, yet the relative 
position of the borders of the organ to the surface of 




Diagram showing the kidneys, and the lower border of the lung behind. 

the body is modified by the nature and amount of its 
contents. 

Spleen. — The spleen is found in the left hypochon- 



16 EXPLORATION OF THE CHEST. 

driac region, just beneath the diaphragm, between the 
posterior border of the stomach and the left kidney. 
It extends from a little above the free border of the 
ribs, at the left axillary line, obliquely upward and 
backward under the lung. About one third of its 
surface is covered by pulmonary tissue. 

Kidneys. — The kidneys are situated in the poste- 
rior part of the abdominal cavity, one on each side of 
the spinal column. The left kidney, which is in con- 
tact at its upper extremity with the posterior border 
of the spleen, reaches from the superior margin of 
the eleventh rib downward nearly to the crest of the 
ilium. The right kidney, which at its upper end is 
beneath the liver, passes from the inferior margin of 
the eleventh rib downward, and is thus somewhat 
lower than the left, 



PHYSICAL METHODS OF DIAGNOSIS, 

Ik accordance with an idea of thoroughness, six 
methods of examination are laid down, and, though 
not of equal value, yet each has its special sphere of 
usefulness. It is too often the custom to disregard 
all means of physical exploration except those of aus- 
cultation and percussion, but the writer hopes to prove 
that in many ways these somewhat neglected methods 
are worthy of consideration. 

The methods of examination here to be used are, 
with one exception, the same that are ordinarily given 
— namely, inspection, palpation, mensuration, calor- 
metation, percussion, and auscultation. 

The term calormetation, a compound of two Latin 
words — color, heat ; metatio, measure — is adopted in 
order to displace succussion, and at the same time 
conform as nearly as possible to the established no- 
menclature. For, though succussion usually occupies 
a position among the methods of exploration, its appli- 
cability is extremely limited ; whereas calormetation 



18 EXPLORATION OF THE CHEST. 

or thermometry receives comparatively little atten- 
tion, while it has a wide range of utility. Succussion, 
which is practically but a form of listening, will be 
described together with auscultation. 

The more essential of the auxiliaries to diagnosis 
are the stethoscope, thermometer, plessor and ples- 
simeter, graduated tape, microscope, and aspirator. 
These will be explained, so far as necessary, in con- 
nection with an account of the methods in which 
they are employed. Among the less needful aids 
may be mentioned the cardiometer, stethometer, and 
sphygmograph. 

INSPECTION. 

The natural commencement of an examination for 
thoracic disease is by inspection, and the information 
thus obtained is by no means unimportant. It con- 
sists in carefully looking at a patient, and looking 
with some definite idea of what appearance a person 
in health should present, as well as of what are the 
numerous variations incident to disease. Attention 
is first directed to the facial expression, the position 
assumed by the patient, and the manner of his breath- 
ing. If pain is depicted on his countenance, the 
mind of the examiner immediately reverts to its prob- 
able cause. He thinks of acute pleurisy, of the pleu- 



PHYSICAL METHODS OF DIAGNOSIS. 19 

ritic stitch that may accompany pneumonia, of inter- 
costal neuralgia, of rheumatism, and of angina pec- 
toris. Experience teaches many fine distinctions be- 
tween these different expressions of suffering. One 
glance may show the anxious, pale countenance, the 
rapid, shallow, catching respiration, the inclination 
forward and to the affected side, of a sufferer from 
acute pleurisy. The face in pneumonia is pale, with 
a dusky flush upon the cheek ; the breathing is very 
much increased in frequency ; there is rapid, panting 
respiration, either with or without dyspnoea ; and the 
posture of the patient is upon the side or the back. 
In angina pectoris there is a deathly pallor, sweat 
stands upon the face, the look is that of agony, and 
the victim seems nailed to the spot where the pain 
seized him. Acute capillary bronchitis produces an 
appearance of extreme distress ; the face, bathed with 
perspiration, is livid, the lips and finger-nails are 
cyanotic, and there is marked dyspnoea with frequent 
orthopnoea ; it being impossible for breathing to con- 
tinue except in the upright position. 

During a paroxysm of asthma there is a most im- 
ploring, terrified expression upon the pale or flushed 
face. "With open mouth, dilated nostrils, and sweat 
starting from every pore, the ill-fated object of these 
seizures fairly gasps for breath, as he clings to the 



20 EXPLORATION OF THE CHEST. 

nearest support that will aid him in his frantic efforts 
to avoid suffocation. In strong contrast are the pal- 
lor, hectic flush, strange luster of the eye, emaciation, 
and placidity, if not buoyancy, of the tuberculous sub- 
ject. Clubbed finger-tips and incurvated nails may 
be found in these cases ; and such a condition of the 
fingers, though existing in other thoracic affections, 
and not always in phthisis, is yet very frequently 
seen in this disease. The emphysematous patient 
presents a dusky, dejected countenance, full face, 
thick nostrils, and prominence of the auxiliary re- 
spiratory muscles upon a rather emaciated neck. His 
attitude is stooping, his breathing slow, labored, and 
very much prolonged. Those affected with heart- 
disease display a bluish red color in the lips after a 
little unwonted exertion, which gives early warning 
of an impaired circulation. And when the balance 
between the venous and arterial systems is much dis- 
turbed, through failure of compensatory hypertrophy 
of the heart, the dark-red color becomes well-marked 
cyanosis, and oedema appears around the instep. 
(Edema, too, is a frequent attendant upon the last 
stage of phthisis. 

Anoemia is shown in a permanent pallor of the 
face or rather of the inner aspect of the lips, for a 
bright flush not uncommonly pervades the cheek. 



PHYSICAL METHODS OF DIAGNOSIS. 21 

Fullness and congestion of the face, with visible pul- 
sation of the carotid and brachial arteries, may be 
found in cardiac hypertrophy. Regurgitation at the 
tricuspid orifice frequently results in pulsation of the 
right jugular vein. Dilatation of a pupil may tell of 
a slight and contraction of a strong aneurismal press- 
ure upon the nerves that come from the cilio-spinal 
center. 

Turning, finally, to the chest, it is better if possi- 
ble to have the covering wholly removed, or from that 
part under immediate observation, so that the slight- 
est inequalities may be seen. Place the patient upon 
a plane surface if he is to be examined while lying 
down, and, if either standing or sitting, arrange his 
body so that the shoulders shall be on a level. Then 
look attentively at the form and movements of the 
chest, which should be viewed from all possible direc- 
tions. A perfectly symmetrical chest is somewhat 
uncommon, but not so rare as to require especial de- 
scription. Reference will be made, however, to a 
few of the slight deviations that occur within physio- 
logical limits, and also to one not infrequent deformi- 
ty, for all irregularities due to extrinsic causes must 
be distinguished from those that are the result of both 
old and recent thoracic disease. The alterations in 
symmetry are expansion, retraction, bulging, and de- 



22 EXPLOKATION OF THE CHEST. 

pression. Bulging is a localized expansion; depres- 
sion, a limited retraction of the chest. There may be 
more or less bulging of the lower portion of the tho- 
rax on the right side behind and on the left side in 
front. 

Depression is often found at the lower end of the 
sternum, and sometimes in the left costal arch. These, 
together with slight deviations of the dorsal spine to 
the right and of the sternum to the right or the left, 
may still be physiological. 

The commonest distortion of the thorax comes 
from a condition known as pigeon-breast, in which 
the sides of the chest are compressed and the sternum 
thrown forward. As a result of this, the customary 
relation of the viscera to the surface is destroyed and 
the accuracy of an examination impaired. 

Now, under what circumstances are changes in 
the shape of the chest found resulting from thoracic 
disease ? They are as follows : A very abundant 
pleuritic effusion produces expansion of the affected 
region. Emphysema (vesicular) results in expansion 
of the whole chest, w^hich is, however, commonly 
more marked upon one side. In pneumothorax there 
is a unilateral .expansion of the upper portion of the 
thorax. Bulging may occur over the region of the 
liver, spleen, or heart from enlargement of these or- 



PHYSICAL METHODS OF DIAGNOSIS. 23 

gans. It may be also the outcome of anetirismal or 
other intrathoracic tumors, of pericardial effusion, or 
of circumscribed pleurisy. 

Ketraction of the chest upon one side frequently 
follows absorption of a long-existing pleuritic effu- 
sion. Unilateral or possibly bilateral retraction is due 
to chronic interstitial pneumonia or fibroid phthisis. 
In narrowness of the antero-posterior diameter of the 
thorax, with deflection of the sternal end of the clavi- 
cle downward, is found an inviting condition for tu- 
bercular deposit at the apex of a lung. Depression 
above and below the clavicle in an otherwise normal- 
ly shaped chest may be one of the signs of phthisis. 
Localized depressions of the chest-wall, more appar- 
ent with inspiration, are significant of pleuritic adhe- 
sions. 

Movements of the Thorax, — When we observe the 
respiratory action of a healthy person who breathes 
quietly, there is seen first an expansion of the lower 
part of the chest, elevation of the upper portion, and 
protrusion of the abdomen, which comprise inspira- 
tion. Following this comes a return of the chest- wall 
to its former position, together with a subsidence of 
the abdomen, which constitute the act of expi- 
ration. 

It will be noticed that the sexes differ in point of 



24 EXPLORATION OF THE CHEST. 

maximum freedom of respiratory movements. The 
upper portion of the thorax takes a much more active 
part in women, whereas the seat of greatest mobility 
with men is at the lower third and in the abdomen. 
Superior and inferior costal are the terms applied re- 
spectively to upper and lower chest breathing, while 
the abdominal play is termed diaphragmatic respira- 
tion. During labored breathing less difference ob- 
tains between man and woman. Respiratory move- 
ments are from eighteen to twenty per minute in 
healthy adults. They are more rapid in women than 
in men, and in children than adults. Both excitement 
and exercise increase the respirations. As a result of 
disease they are either increased, diminished, or la- 
bored. Where the ratio is greater than one respira- 
tory act to four cardiac pulsations, pulmonary lesions 
may be suspected. Breathing is increased by pleu- 
risy, phthisis, pneumonia, and bronchitis of the small- 
er tubes. It is frequently diminished to avoid pain, 
as in the first stage of pleurisy, in intercostal neural- 
gia, and in pleurodynia. Breathing is less frequent 
on the side of the chest that contains a fluid effusion 
and more rapid than normal upon the other side. 
Respiratory action becomes labored in emphysema, 
asthma, and acute capillary bronchitis ; and, while 
either diminished or absent in hydropneumothorax on 



PHYSICAL METHODS OF DIAGNOSIS. 25 

the affected side, it is also labored as well as dimin- 
ished on the unaffected side. 

Thus inspection narrows the possible state of af- 
fairs down to a few conditions which, if somewhat 
closely resembling one another, can be differentiated 
by the test of other methods. And this exemplifies 
what holds throughout physical exploration. One 
sign is never to be trusted for diagnosis, but rather 
the combined testimony of several signs. 

Sputa. — Extending the investigation from the 
chest to the material expectorated may prove invalu- 
able in diagnosticating thoracic disease. As an aid to 
this examination comes the microscope, whose ma- 
nipulation, however, must be learned from books 
devoted to that subject. Blood from a bronchial 
haemorrhage is bright red and frothy in appear- 
ance. 

The expectoration of acute bronchitis, at first 
frothy mucus and scanty in amount, soon becomes 
muco-purulent and abundant. That of acute bron- 
chitis affecting the smaller tubes, capillary bronchitis, 
consists in casts of the small tubes mixed with mucus 
from the large. When placed in water the mucus 
floats on the surface, and the casts hang by small, 
stringy connections beneath. 

In chronic bronchitis, though the expectoration 



26 EXPLORATION OF THE CHEST. 

may be either profuse and watery, or else scanty, 
sticky, and perhaps streaked with blood, yet more 
commonly it is muco-purulent, green or yellow in 
color, and of varying quantity. 

"With fibrous bronchitis little masses of fibrin 
tinged with blood are expelled, which, dropped into 
water, prove to be membranous casts of the bronchi. 
Some of these casts are cylindrical and others are 
branch-like in form, and their presence determines 
the nature of the bronchitis. 

(Edema of the lungs is attended by a profuse, 
frothy, serous expectoration. Congestion, which is 
usually associated with more or less oedema, produces 
blood-stained, frothy mucus. 

The material thrown out from cancer of the lungs 
resembles red-currant jelly. 

The expectoration of phthisis varies both in ap- 
pearance and amount. At first a meager, glairy, 
frothy mucus, here and there dotted with purulent 
matter, it ere long becomes niuco-purulent and copi- 
ous, and in the end possibly purulent and excessive. 
It may, too, be somewhat streaked with blood. Frag- 
ments of elastic tissue found upon microscopical ex- 
amination indicate a destruction of lung- substance. 
The Bacillus tuberculosis, a species of bacteria, is 
found so constantly in the sputa of phthisis under the 



PHYSICAL METHODS OF DIAGNOSIS. 27 

microscope, that, while its absence does not necessa- 
rily preclude the existence, its presence is very sig- 
nificant of the disease. 

Scarcely less characteristic than the casts of fibrin- 
ous bronchitis are the sputa of pneumonia. In fact, 
they become one of the most reliable signs where the 
pneumonic process is central ; still, it must not be for- 
gotten that inflammation of the lung proceeds now 
and then without expectoration. During the first two 
days the sputum is a glairy, frothy mucus ; w T hich 
gradually becomes extremely viscid — so tenacious, in- 
deed, that it is expectorated often with difficulty. If 
deposited on a piece of paper for inspection, it as- 
sumes a nearly globular shape, and is found to be a 
gelatinous, translucent body, sometimes surrounded by 
a zone of frothy mucus. Turning the paper upside 
down will not dislodge this sticky material. It varies 
from a faint amber to a brick-dust color, according to 
the amount of blood with which it happens to be 
tinged. This is known as rusty sputa, and is peculiar 
to pneumonitis. As the disease advances, the sputa 
become less sticky, the brick-dust color gradually dis- 
appears, and, finally, with resolution there is a mod- 
erate muco-purulent expectoration. But if the malady 
terminates in suppuration, the matter expelled will be 
abundant and purulent. And when the sputa are 



28 EXPLORATION OF THE CHEST. 

dark brown in color, watery, and diffluent, they pre- 
sage an unfavorable termination to the disease. 



PALPATION. 

The method known as palpation consists in the 
gentle application of the palmar surface of the fingers 
to the body of the patient ; and when the thorax is 
under examination, this should be simultaneously per- 
formed upon both sides, for the sake of comparison. 

In doing this, not only the form, size, and move- 
ments of the chest can be appreciated, but also the 
vibrations of the patient's voice, as they are conducted 
through the lungs to the hand. It is this last func- 
tion of palpation which constitutes the chief useful- 
ness of the procedure. These vibrations, termed nor- 
mal vocal fremitus, are most pronounced upon the 
right side of the chest, and especially from the clavi- 
cle down to the third rib. Fremitus is regulated very 
much by the quality of the voice, as well as by the 
thickness of the parietes. For, while appreciable in 
the lower register of an adult, it may be entirely ab- 
sent from a treble voice ; and, though easily felt 
through a thin chest, a large deposit of adipose tissue 
will interfere with its transmission. 

Yocal fremitus may be increased, diminished, or 



PHYSICAL METHODS OF DIAGNOSIS. 29 

absent, as a result of thoracic disease. Whatever 
increases the density of the lung, as compression, 
or the consolidation of phthisis and pneumonia, 
augments it. Now and then fremitus is not only 
not increased, but is even absent, with extensive 
solidification. And this sign is nullified by the in- 
terposition of a plastic exudation or of normal pul- 
monary tissue between the surface and the consol- 
idation. 

When there is either air or fluid between the lung 
and the parietes of the pleural cavity, the fremitus 
decreases, or wholly disappears. For instance, it is 
not found in pneumothorax, subacute pleurisy, empy- 
ema, hydrothorax, nor hemothorax. Nevertheless, 
this rule is not absolute, as fremitus will continue in 
some instances despite a large effusion. 

By the application of the hand in pleurisy one 
can often detect friction, which the rubbing of the 
pulmonary against the parietal pleura produces. This 
is known as friction fremitus. And likewise in bron- 
chitis the vibrations of sibilant and sonorous breath- 
ing are sometimes felt. This is called rhonchal 
fremitus. 

The respirations are counted in men by resting 
the finger-tips upon the abdomen, and in women upon 
the superior costal region — because the mobility of 



30 EXPLOKATION OF THE CHEST. 

the chest is more marked at this place in women, 
while in men, on the other hand, breathing is chiefly 
diaphragmatic. 

MENSURATION. 

There are numerous ingenious contrivances for 
measuring various areas of the chest, but for practical 
purposes a graduated tape will suffice. 

Two measurements are commonly made — one of 
the circumference, on a level with the sixth costo- 
sternal articulation, the other of the semi-circumfer- 
ence, at this same height. For accuracy, a mark 
should be drawn with the cosmetic pencil, at the me- 
dian line, in front over the sternum and behind over 
the spinous process. 

An average adult thorax measures thirty-three 
inches around, and the right side is usually half an 
inch the larger. "With left-handed persons this side 
is found to exceed the right in size. Hence an allow- 
ance must be made for this physiological inequality 
when either abnormal enlargement or reduction is sus- 
pected. 

The expansion of the chest during ordinary inspi- 
ration is about one quarter of an inch. Between 
forced inspiration and extreme expiration, however, 
it is from two and a half to four inches. 



PHYSICAL METHODS OF DIAGNOSIS. 31 

We have already dwelt upon the diseases that di- 
minish expansion. They are such as result in adhe- 
sions of the pleura with contraction of the lung, in 
effusions of the thoracic cavity, in consolidation of the 
lung, and in extensive dilatation of the air-cells. A 
large effusion would decrease the inspiratory expan- 
sion of the involved side, and at the same time in- 
crease its semi-circumference ; while hepatization of 
the lung would also lessen expansibility, but not in- 
crease the measurement of the affected side. 

Furthermore, adhesions of the pleura with retrac- 
tion of the chest diminish both movement and semi- 
circumference. 

The circular measurement of the lower part of the 
chest in vesicular emphysema is sometimes decreased 
by a full inspiration, and higher, at the same time, 
there is very little expansive mobility. 

CALORMETATION. 

The importance of measuring the temperature, as 
a method of physical examination, is based upon the 
fact that in healthy adults the heat of the body main- 
tains itself at about the same daily average under all 
circumstances ; whereas, during disease, in many in- 
stances, the temperature not only varies, but also pur- 



32 EXPLORATION OF THE CHEST. 

sues a somewhat characteristic course. Although the 
presence of a normal temperature does not insure the 
absence of disease, a persistent elevation above the 
normal, or a like depression below the established 
average, would be considered an abnormal manifesta- 
tion ; and, furthermore, sudden elevations or abrupt 
depressions of temperature are often the harbingers 
of momentous crises. Conjoined with other signs, an 
isolated observation may serve to exclude the exist- 
ence of certain conditions ; but, ordinarily, it requires 
repeated investigations at stated intervals to reach sat- 
isfactory conclusions. 

The average temperature of a healthy adult, when 
properly taken in the axilla, is 98*6° Fahr., and the 
daily fluctuations do not much exceed one degree. 
In children the average temperature is higher and the 
diurnal variations are greater, there being often a fall 
of one, two, or even three degrees during the latter 
part of the twenty-four hours. Women, and espe- 
cially those having nervous temperaments, somewhat 
resemble children in mobility of temperature. 

Within the rectum or the vagina the mercury 
rises nearly a degree higher than at the axilla, while 
in the mouth the index falls a little short of axillary 
heat. A permanent elevation above 99*5° Fahr., or a 
continuous depression below 97*5° F., in the axilla, 



PHYSICAL METHODS OF DIAGNOSIS. 33 

signifies something abnormal ; and an increase of two 
degrees from 98*6° F. is a pretty certain indication of 
fever. Temperature averaging slightly above 100° F. 
is found with many chronic maladies. At 102° F. 
fever may be considered moderate, at 105° F. severe, 
at 107° F. dangerous; and if maintained for more 
than a day at 107*6° F. it would probably portend a 
fatal termination to the disease. It is not so much 
the height as the persistence of the elevation that 
bodes danger, for in malarial affections there may be 
a temporary rise to 106° F. or even to 107° F. with- 
out exciting great fear. Patients with temperatures 
reaching 110° F. and higher have recovered. A de- 
pression to 96'S° F. may be considered alarming, al- 
though the region of greatest danger in collapse is 
thence downward. Children often develop very high 
temperatures upon slight provocation, whereas old 
people, on the other hand, frequently reach very criti- 
cal conditions without the customary febrile mani- 
festations. 

With respect to the methods of procedure in ther- 
mometrical observations, one may possibly detect the 
presence of fever by the hand if applied to unexposed 
parts of the body, but for anything approaching ac- 
curacy a clinical thermometer should be employed. 
The tyro in medicine is often misled by finding face, 



34 EXPLORATION OF THE CHEST. 

hands, and feet cold when a thermometer would reg- 
ister a high degree of temperature either in the rec- 
tum, the axilla, or the month. Self -registering clin- 



Thermometer. 

ical thermometers are at all times to be preferred. 
Such an instrument is composed of a glass tube of 
capillary bore from four to six inches in length, on 
which is a graduated scale ranging from 90° to 110° 
F. This tube is closed at the upper end, while at the 
lower end it expands into a bulb which is filled with 
mercury. Within the canal there is a small section 
also of this metal separated from the main body by a 
little air for an index ; moreover, a twist in the glass 
tube prevents a reunion of this index with the re- 
mainder of the mercury. 

To set the index, let the student grasp the instru- 
ment between his thumb and first finger and strike 
the thenar eminence of one hand upon that of the 
other until the upper end of the mercury falls below 
the place on the stem marked normal ; but as ther- 
mometers are expensive and of necessity fragile, it is 
well to perform this manoeuvre over a bed, should 
one be at hand, so that if by chance the instrument 



PHYSICAL METHODS OF DIAGNOSIS. 35 

slip it will not break upon falling ; and while carried 
in the waistcoat-pocket there is likewise danger that 
the thermometer will be dropped and broken. This 
can be obviated by the simple and easy expedient of 
closing part of the aperture with a safety-pin. 

A thermometer should be tested from time to 
time with some standard instrument in warm water, 
and the disparity, if any, between the elevation of 
the indices noted. 

Whether to put the thermometer into the mouth, 
the axilla, or the rectum, must be determined some- 
what by circumstances. Considerable time can be 
saved by sufficiently warming the bulb of the instru- 
ment, before insertion, to raise the mercury to the 
place marked normal. 

If the temperature is taken in the mouth, the 
bulb of the instrument must be held beneath the 
tongue, the lips kept closed, and the patient, for obvi- 
ous reasons, should breath through the nose. If in 
the rectum, the thermometer should be oiled, and, 
after the bowels have been emptied, gently intro- 
duced. If in the axilla, which for many reasons is 
the most suitable spot, care must be taken to wipe the 
place dry, to insert the bulb beneath the pectoral fold, 
and to see that nothing comes between the instrument 
and the skin. Having attended to these precautions, 



36 EXPLORATION OF THE CHEST. 

let the student draw the arm of the patient across the 
chest, and retain the limb in this position, in order to 
close the axilla and to keep it closed. And, in addi- 
tion, it is well to cover the shoulder with some article 
of clothing, while at the same time it is important 
during the observation to make sure that the ther- 
mometer remains in place. The time required for an 
adequate approximation of the index to its point of 
maximum elevation is from five to seven minutes, 
providing the above details have been complied with. 

The frequency of the observation should be de- 
cided somewhat by the urgency of the case, though 
temperatures are ordinarily taken at least twice in the 
day, at about eight in the morning and at five o'clock 
in the evening. 

Finally, a record should be made of these fluctua- 
tions of temperature, in the form of a chart, which 
should be preserved for daily inspection. 

TEMPERATURE UN" DISEASE. 

Bronchitis. — A catarrhal inflammation of the 
trachea and bronchi may produce no alteration in the 
temperature beyond the regular daily physiological 
fluctuation. Still, there is often slight fever at the 
commencement of the disease, and from time to time 



PHYSICAL METHODS OF DIAGNOSIS. 37 

during its progress ; and children frequently have 
severe pyrexia with these affections. The intensity 
of the fever, more especially with an adult, indicates 
the amount of the inflammation. But the importance 
of thermometry in bronchitis, however, rests mainly 
upon the contingent complications, which announce 
themselves by sudden elevations of temperature. 

Pneumonia. — In acute lobar pneumonia the tem- 
perature usually rises quickly to 103'5°-104: , or 
even to 106° F. Here it continues, with daily fluc- 
tuations of one or two degrees, until defervescence, 
which is either abrupt or gradual. A rise of the 
index above 104° F. would indicate considerable fever. 
Still, patients with a moderately high fever often do 
best in the end. Pyrexia is supposed to continue 
with the progress of the inflammation, and a sudden 
increase in the intensity of the fever signifies that a 
new lobe is invaded, or that some complication has 
supervened. 

The temperature of lobular pneumonia takes an 
irregular course ; the rise is more gradual, the aver- 
age less high, and defervescence is more protracted, 
than in lobar pneumonia. 

Pleurisy. — The range of temperature with inflam- 
mation of the pleura is variable. In some instances 
there will be considerable fever, in others but a mod- 



38 EXPLORATION OF THE CHEST. 

erate amount, while in many cases there will be 
no febrile manifestation. When there is pyrexia, 
it usually does not exceed 103° F. ; and, moreover, 
it is remittent in type, and has a gradual abate- 
ment. 

Haemoptysis. — Most pulmonary hemorrhages that 
are copious depress the temperature, and when the 
bleeding is excessive the depression may reach 
96*8° F., or even fall below this mark. A reaction 
from the collapse would be followed by a renewal 
of any pre-existing fever. 

Acute Miliary Tuberculosis. — A sudden rise of the 
temperature, not otherwise accounted for, in a case of 
chronic phthisis pulmonalis, suggests the not unlikely 
complication of acute miliary tuberculosis. There is, 
however, nothing characteristic about the range of 
the fever in this affection, except, perhaps, a rather 
pronounced matutinal elevation. 

Chronic Phthisis Pulmonalis. — Pyrexia prevails 
during the progressive stages of phthisis, so that a 
daily afternoon appearance of fever, however slight, 
would increase the weight of testimony in favor of 
the presence of this malady should diagnosis be un- 
certain. 

Frequently there is no febrile movement for a 
time, or there may be a rise only in the evening, or 



PHYSICAL METHODS OF DIAGNOSIS. 39 

else a morning elevation with, a moderate increase 
toward the night. Death, in some instances, is pre- 
ceded by a fall 3 in others by a decided rise of tem- 
perature. 

Cancer of the Lung. — The temperature in pulmo- 
nary cancer either remains normal or slightly falls, 
except during intercurrent attacks of pleurisy, or 
of pneumonia, when there will be more or less 
fever. 

Uncomplicated asthma, emphysema, oedema, and 
hydrothorax exist without fever. 

Endocarditis and Pericarditis. — With an attack of 
articular rheumatism there may be either endocarditis 
or pericarditis without an increase of the temperature 
over what obtains, save that during convalescence the 
fever remains somewhat higher than in uncompli- 
cated cases ; and, too, some time after the joint 
trouble has disappeared, there may be a decided ele- 
vation of temperature caused by a fresh development 
of valvulitis. 

Chronic Heart-Disease. — There is no rise of tem- 
perature in chronic heart affections. It is upon the 
supervention of acute attacks or of some complicating 
disease that fever is generated. 



40 EXPLORATION OF THE CHEST. 

TEMPERATURE TABLE. 

Normal, 

98-6° F. 37° C. 

Fever. 

Slight 100-4° F. 38° 0. 

Moderate 102-2° 39° 

Severe 105-8° 11° 

Dangerous 107-6° 42° 

Collapse. 

Slight 96-8° F. 36° C. 

Moderate 95-0° 35° 

Severe 93-2° 34° 

Fatal 91-4° 33° 

98-6° F. equals 37° C. 
100-4° " 38° 

102-2° " 39° 

104-0° " 40° 

105-8° " 41° 

1-8° " 1° 

Multiply centigrade by 1-8° F. and add 32° to ob- 
tain Fahrenheit. 



PERCUSSION. 

Percussion is the act of striking the body in a 
certain prescribed manner to determine the relative 
amount of air and solids therein contained, to detect 
the presence of fluids, to define the viscera, and to 



PHYSICAL METHODS OF DIAGNOSIS. 41 

locate tumors. This method embraces a wide field 
of investigation, and its proper performance requires 
both care and considerable practice. Therefore, 
close attention should be given not only to the sub- 
ject in general, but also to the details of manipula- 
tion. 

In the first place, oftentimes a student is found 
to be rather too literal in his interpretation of " strik- 
ing the chest," and thereby the patient nearly gets a 
pummeling. Although forcible blows become neces- 
sary upon very thick tissues and over deep-seated so- 
lidification, yet, as a rule, gentle strokes, except under 
these circumstances, are productive of the most satis- 
factory results. 

There are two methods of percussing : one is di- 
rectly upon the body, which is termed immediate; 
the other is upon some interposed substance, and is 
called mediate percussion. The former is mainly con- 
fined to exploration of the clavicles, where the bones 
themselves answer for pleximeters. 

A pleximiter or plessimeter is a flattened oval disk, 
either of vulcanite or ivory, turned up at each end to 
be conveniently handled. 

A plexor or plessor is a small rubber hammer in 
the shape of a double cone, fastened at the center to 
a vulcanite handle. 



42 



EXPLORATION OF THE CHEST. 



But, notwithstanding these auxiliaries, percussion 
is commonly practiced with the unaided fingers, and, 

while requiring greater dexter- 
ity, it is in many ways prefera- 
ble : First, by using the fin- 
gers, w^hich are also better 
adapted to the inequalities of 
the chest, much extraneous noise is eliminated ; sec- 
ond, the sense of resistance communicated to the 




Pleximiter. 




Plexor. 



hands is of very great value ; and, third, their avail- 
ability is enhanced by being ever present w T hen 
needed. 

During exploration, when a matter of choice, the 
person examined should be seated. For percussion in 
front the body should be erect but unstrained, the 
shoulders on a level, and the arms hung loosely by 
the side. The detection of slight dullness is fur- 
thered by placing the patient's back against a thin 
door for the re-enforcement of sound. 



PHYSICAL METHODS OF DIAGNOSIS. 43 

For percussion behind, have him cross his arms, 
put a hand on each shoulder, then elevate his elbows, 
and slightly incline his head forward. 

For percussion at the side, let him clasp his hands 
over his head. 

But if the patient is unable to sit up, see that 
his body rests upon a plane surface, with his 
muscles relaxed and limbs placed symmetrically. 
It is always better to percuss upon bare skin, yet 
if there be no alternative, which is often the case 
with women, some unstarched garment can be 
worn. 

The examiner, assuming a position directly oppo- 
site the person to be examined, makes a pleximeter 
either of the index or middle finger by placing its 
palmar surface firmly upon the chest along a rib or 
an interspace. He then flexes the index, middle, and 
ring fingers of the other hand until their conjoined 
ends present an even surface for the plexor or ham- 
mer. With this plexor each blow should be deliv- 
ered upon the pleximeter vertically from the wrist, 
with care that the strokes be equable, fairly rapid, 
and quickly receding. Moreover, he must avoid strik- 
ing with the finger-nails on the one hand or upon 
them on the other hand ; and the pressure of the 
pleximeter as well as the stroke of the plexor must 



44 EXPLOEATIO^ OF THE CHEST. 

be uniform for like parts on the two sides of the 
chest. 

Light percussion can be performed by the middle 
finger with the impulse partly from the metacarpo- 
phalangeal joint. 

Lastly, never percuss at random, nor indifferently 
as to the breathing, but at all times with an idea of 
comparing corresponding areas, and at the same rela- 
tive respiratory act. For there is a normal difference 
between the resonance developed over a rib and that 
over an interspace, and likewise between the reso- 
nance at the end of inspiration and at the close cf ex- 
piration. The pitch is higher o^er a rib than an in- 
tercostal space, and upon a held inspiration than a 
forced expiration. 

The difficulty of percussion seems to be in mak- 
ing a clear light stroke from the wrist ; many begin- 
ners are apparently seized with a gwm-anchylosis of 
this joint. Still, all obstacles can be overcome by pa- 
tience and application. 

Physical diagnosis makes but a slight draught 
upon acoustics, and the student should have little 
trouble in grasping these few principles. 

Sounds developed by percussion have the distinct- 
ive attributes of quality, pitch, intensity, and dura- 
tion. Now, the ear does not require much cultiva- 



PHYSICAL METHODS OF DIAGNOSIS. 45 

tion to distinguish between the musical sounds of a 
flute and those of a piano, even when the note and 
pitch are the same. This is because of the different 
inherent quality in the tones, due in part to the form 
of the vibrations. So, in percussion, one recognizes 
pulmonary resonance, flatness, etc. (although not mu- 
sical sounds), by their innate quality. 

It is not difficult to decide between the bass and 
high treble notes of a piano ; the former are low-, the 
latter high-pitched tones. A similar difference exists 
in the pitch of sounds evolved by percussing the 
chest. Pitch depends solely upon the number of vi- 
brations that take place in a given time. Tension, 
by increasing the rapidity of the vibrations, raises the 
pitch; relaxation, on the contrary, by decreasing their 
rapidity, lowers the pitch. 

To continue wdth the piano-forte for illustration, 
pressure of the foot upon the hard pedal augments 
the loudness of the note struck, and upon the soft 
pedal diminishes the sound. This is accomplished 
by regulating the size of the vibrations; the large 
produce loud, the small develop soft tones. Here 
is shown the greater and the lesser intensity of 
sound. 

The intensity or loudness of a percussion note 
varies with the texture of the thoracic parietes, the 



46 EXPLORATION OF THE CHEST. 

quantity of contained air, and the forcibleness of the 
blow. 

Duration is simply the continuance of sound, and 
this is exemplified by holding down a piano-key either 
a longer or a shorter time. 

RECAPITULATION. 

Quality : Distinguishing inherent character. 
Pitch : Elevation of tone ; depression of tone. 
Intensity : Amplitude of vibrations ; loudness. 
Duration ; Time of continuance of sound. 

Resonance. — The different kinds of sounds devel- 
oped by percussion are normal, pulmonary, or vesicu- 
lar resonance ; dullness ; flatness ; tympanitic reso- 
nance ; vesiculotympanitic ; and two other modifica- 
tions of tympanitic resonance, termed respectively 
amphoric resonance and cracked-pot sound. 

It is almost needless to say that a more adequate 
conception of these sounds can be obtained by listen- 
ing to them than from any description of them, the 
fact is so evident. Therefore let the student select a 
thin, healthy adult, whose thorax is nearly symmet- 
rical, and uncover his chest in a room that has been 
suitably warmed. Now observe all directions as to 
manipulation, and percuss in the region from the left 



PHYSICAL METHODS OF DIAGNOSIS. 47 

clavicle down to the third rib. Here is evolved nor- 
mal pulmonary or vesicular resonance, a rather in- 
tense, prolonged, low-pitched sound, which has the 
quality known as vesicular. Moreover, the pitch, in- 
tensity, and duration are peculiar to this individual, 
and serve for a key-note, as it were, to the resonance 
in other parts of his chest ; for it will be found that 
vesicular resonance varies in pitch and intensity with 
different persons. Then percuss on the right side in 
front, just below the fifth rib, where the liver is cov- 
ered by a thin layer of lung. The aerated lnng and 
the solid liver-tissue combined give a modified ve- 
sicular resonance called dullness, which is short, rather 
high-pitched, and only moderately intense — a quality 
of resonance that ranges from slight to complete dull- 
ness, according to the relative proportions of air and 
solid material. 

Again, percuss in the same region below the ex- 
tension of the lung, and a short, high-pitched note 
of slight intensity will be developed. This has the 
quality known as flatness, for here the sound comes 
not from the lung containing more or less air, but 
rather from an almost solid body. 

Percussion below the left nipple, in the region of 
the stomach, if this organ is distended by gas, will 
produce an intense, prolonged, usually high-pitched 



48 EXPLORATION OF THE CHEST. 

sound, termed tympanitic resonance. Over the in- 
testines, on the other hand, unless greatly filled with 
air, the pitch of the note will be low, but, whether 
the pitch be high or low, the quality of this sound 
remains tympanitic. 

Vesiculotympanitic resonance, as the name im- 
plies, is a combination of vesicular with tympanitic 
resonance, and this union determines its quality. 
Hence, with considerable intensity, there are varia- 
tions of pitch and duration, as either tympanitic or 
vesicular resonance predominates. Percussion over 
the apex of the lung, toward the trachea, sometimes 
develops a mixture of the vesicular resonance, with 
a tympanitic sound from the trachea — vesiculo-tym- 
panitic. This, however, is much better illustrated 
by the disease emphysema, in which it frequently 
occurs. 

Cracked-pot sound can be produced by percussing 
a little below the clavicles in some adults and in many 
children. It is a chink-like sound, represented by 
striking the back of one hand, while clasped in the 
other, upon the knee. 

Amphoric resonance is auto-demonstrable by a 
slap upon the cheek while the lips are closed and the 
mouth is moderately inflated. 

Regional Percussion in Health. — Every student that 



PHYSICAL METHODS OF DIAGNOSIS. 49 

takes the trouble to follow the directions which are 
given for learning the different kinds of percussion 
resonance, will find that he is rewarded for his trouble 
by a much clearer idea of what these sounds are than 
could possibly be secured without this objective meth- 
od. The next step is to make a systematic examina- 
tion of the normal chest, and thereby map out the 
regions where vesicular resonance, dullness, flatness, 
etc., properly belong. First, however, let us consider 
some of the individual peculiarities, for chests differ 
materially. 

Resonance is modified by age, by sex, by respira- 
tion, and by the thickness of the overlying tissue. 
Therefore, one person can not be taken as a standard 
for another; the "key-note" must be sounded in each 
instance. 

In youth the thoracic wall is elastic ; consequently 
resonance is lower in pitch and of greater intensity 
than in old age. 

The intensity is usually greater and the pitch 
lower in women than in men. 

A very full held inspiration may put the muscles 
into such tension, and so inflate the lung, as to raise 
the pitch, whereas the pitch is lowered at the end of 
expiration. Still, this disparity is not observable in 
every person. 

3 



50 EXPLORATION OF THE CHEST. 

That there should be an increase of intensity with 
a rise in pitch, contrary to what happens in dullness 
or in flatness, is possibly explained by an elevation of 
pitch being due, in the one instance, to aeriform ten- 
sion with resulting hollowness, and in the other to ten- 
sion from increased density which amounts to solidity. 

Where chests are covered by heavy muscles the 
percussion note is raised, the duration shortened, and 
the intensity diminished. This is liable to lead an 
unwary observer to conclude that there is consolida- 
tion of lung beneath, when a cautious examiner, by 
availing himself of comparison, would avoid such a 
mistake. And in this we find an example of the in- 
adequacy of sensation, unassisted by comparison and 
experience. 

Now, with these few points in mind, let the stu- 
dent gently percuss the lung on each side above the 
clavicles ; and at the same time see that the mouth 
of the person examined is open, and that the stroke is 
not directed toward the trachea. Here there is ve- 
sicular resonance, but with pitch sufficiently high to 
constitute moderate dullness. 

Upon the clavicles — and immediate percussion is 
best over these bones — there is vesicular modified by 
osseous resonance. 

Upon the right side in front, from the lower mar- 



PHYSICAL METHODS OF DIAGNOSIS. 51 

gin of the clavicle to the fifth rib, normal vesicular 
resonance is found. The pitch is somewhat higher 
than on the left side. Thence to the lower border of 
the lung, where it shelves over the liver, there is dull- 
ness, and below, nearly to the free border of the ribs, 
flatness. But a tympanitic quality is frequently trans- 
mitted from the intestines through the lower margin 
of the liver. 

It is a matter of interest, having found the upper 
line of liver flatness, to note the amount of respira- 
tory play in the lung. This is shown by percussing 
from that level downward, after a full insj:>iration 
while the person examined holds his breath. With a 
deep inspiration the lung glides in between the plex- 
imeter and liver, and flatness disappears to the extent 
of the lung's excursion. On the other hand, forced 
expiration elevates the upper limit of flatness, and 
thus the extremes of pulmonary mobility are illus- 
trated. The position of the lower border of the lung 
fluctuates not only with respiration, but also with the 
posture of the body. It travels an inch or more in 
calm breathing, so that the exact lower boundary of 
the organ depends somewhat on the attitude of the 
person, and very much on the rhythm of the respira- 
tory act. 

On the left side in front, from the lower edge of 
i 



52 EXPLORATION OF THE CHEST. 

the clavicle to the third rib, there is vesicular reso- 
nance. From the third rib downward, where the lung 
overlaps the heart, there is dullness, and, as a rule, 
flatness over the uncovered heart. This region of flat- 
ness is affected by the locomotion of the lung, for flat- 
ness can be made almost to disappear on full inspira- 
tion. Downward from the sixth rib, if the stomach 
is well distended by gas, there will be tympanitic 
resonance. 

From the upper margin of the sternum to nearly 
the fourth costo-sternal articulation there is resonance 
of considerable intensity, which is in quality peculiar 
to the sternum ; and, though it may extend down 
the entire bone, yet sometimes, and especially if the 
person examined be inclined forward, forcible percus- 
sion develops dullness. 

Over both scapulae the pitch is high and it 
amounts to dullness, but not complete dullness, for an 
underlying consolidation can still be detected by com- 
paring the resonance of the two sides. 

Between the scapulae and the vertebral column 
there is vesicular resonance. 

From the lower angle of the scapula, on both sides, 
there is vesicular resonance down to about the tenth 
rib, with flatness thence downward. Here the limit 
of flatness is influenced by the shifting lower border 



PHYSICAL METHODS OF DIAGNOSIS, 53 

of the lung, and the line 'of demarcation is a little 
higher on the right side because of the liver. 

In the right axillary line there is vesicular reso- 
nance down to about the fifth intercostal space, with 
dullness from here to the seventh rib, and flatness 
down to the free border of the ribs. 

In the left axillary line there is vesicular reso- 
nance to the sixth intercostal space ; and thence down- 
ward, if the stomach be inflated, there is tympanitic 
resonance. Still, in this area, by gentle percussion, 
flatness may be developed from the ninth to the 
eleventh rib, over the spleen ; but, if the stomach be 
full of food, there will be either dullness or flatness 
where there was tympanitic resonance. 

Auscultatory Percussion. — Some zealous examiners 
have undertaken to define the viscera by sounds pecul- 
iar to each organ. But, although it is possible for 
disparate surroundings to somewhat influence reso- 
nance, yet the flatness of one viscus will be found 
not to differ essentially from that of another. 

On the other hand, Clark and Cammann greatly 
added to the facility of defining the viscera by the 
introduction of auscultatory percussion. This con- 
sists in what may be termed supplementary percus- 
sion — i. e., a stethoscope is employed to conduct reso- 
nance to the ear, while the stroke is delivered by 



54 EXPLORATION OF THE CHEST. 

either the listener or another. An instrument has 
been made with its objective extremity in the form 
of a truncated wedge, in order to fit the intercostal 
spaces, and thus establish closer communication with 
the underlying substance. 

Respiratory Percussion. — A system of percussing 
with the breath of the one examined in suspense, now 
at the end of full inspiration, and then at the close of 
forced expiration, is entitled, by Da Costa, respiratory 
percussion. The efficacy of this plan depends upon 
the fact that resonance, in many instances, is mate- 
rially altered by respiration. For example, a full in- 
spiration, when held, not only increases the intensity, 
but also raises the pitch, while forcible expulsion of 
the air both lessens intensity and lowers pitch. 
Neither expedient, however, changes the relative dif- 
ference between the two sides. 

It is the first measure that proves most serviceable, 
especially when associated with the improvised sound- 
ing-board, by bringing into high relief, as it were, the 
at best slight dullness of incipient phthisis. More- 
over, advantage is taken of respiratory percussion to 
distinguish consolidation from collapse of the lung. 
For a full and held inspiration often diminishes dull- 
ness of the latter, whereas in the former the sign re- 
mains unaltered. This applies particularly to bron- 



PHYSICAL METHODS OF DIAGNOSIS. 55 

chitis of the smaller tubes, in which dullness may 
occur from either collapse of the lobules or consolida- 
tion of a complicating lobular pneumonia. Further- 
more, recourse may be had to respiratory percussion, 
as a means of definitely determining upon the line of 
demarkation between a compressed lung and the flur 
of a pleural effusion ; for an increase of volume in 
the air of a compressed lung augments the intensity 
of the resonance, and thereby renders the change to 
flatness more apparent by contrast. 

Percussion in Disease, — It is essential, withal, to 
have some general conception of the physical signs of 
disease, as demonstrated by percussion, before under- 
taking the examination of individual cases. Sounds 
that are normal in one place are abnormal in another 
place, and evince disease ; and, moreover, changes 
in some of the distinctive attributes of sound have a 
like meaning, without a change of locality. 

Take, for example, flatness, which we found with- 
in certain defined areas, over the liver, the heart, and 
the spleen. Now, an extension beyond these limits 
may be due either to enlargement or displacement of 
the viscus, or else to a recession of what overlaps its 
borders ; a falling short, on the other haiid, may be 
from a diminution in the size of the organ, or from 
some encroachment upon its surface. Again, should 



56 EXPLORATION OF THE CHEST. 

flatness be discovered elsewhere in the chest, it would 
be one of the signs of a fluid effusion, of entire con- 
solidation, of thick pleuritic adhesions, or of a tumor. 

In a similar manner, when tympanitic resonance, 
normal over the gastric region in health, is evolved 
from other parts of the chest, it becomes one of the 
indications of pneumothorax, and possibly of a large 
air-containing cavity in phthisis. Now and then, too, 
this resonance can be heard over solidified lung, in 
which it is generated by the air of the bronchi. 

An alteration in some of the attributes of reso- 
nance is exemplified when slight dullness, where it 
exists normally, reaches complete dullness, with a cor- 
responding rise in pitch and decrease of intensity. 

The solidification of phthisis and of pneumonia, 
as well as of compressed lung, gives dullness. There 
will be dullness from an extensive pulmonary oedema, 
from a large haemorrhage in the lung, and from mod- 
erate pleuritic adhesions. 

"Within the area of normal vesicular resonance the 
pitch may be raised and the intensity exaggerated, 
from vicarious breathing. This change of pitch and 
intensity, which practically amounts to vesiculotym- 
panitic resonance, is sometimes developed over a lung 
that is condensed but not collapsed by an effusion. 
And, moreover, where one lobe is hepatized, such 



PHYSICAL METHODS OF DIAGNOSIS. 57 

resonance may be found in the unaffected portion of 
the lung. It occurs also in extensive emphysema. 

Amphoric resonance is heard in pneumothorax 
and over a large, empty pulmonary excavation with 
tense walls. 

Cracked-pot sound is developed over cavities with 
flaccid walls. It may escape observation, however, 
unless the examiner during percussion place his ear in 
close proximity to the patient's open mouth. This 
sound is not peculiar to vomicae, for it is audible in 
some instances over a compressed or a solidified lung 
and in the chests of many healthy children. 

From the foregoing account of the physical mani- 
festations of disease it is seen that a single sign has 
not so much an absolute as a relative significance ; 
and by keeping this fact in sight physical exploration 
is made less disappointing than by always looking for 
signs that are pathognomonic. Every intelligent diag- 
nostician draws his conclusions from a combined tes- 
timony not only of signs but of symptoms as well. 

RECAPITULATION OF RESONANCE. 

Vesicular : Uncomplicated lung. 

Dullness : Lung with increased proportion of solids. 

Flatness : Solids, fluids. 

Tympanitic : Large body of air. 



58 EXPLORATION OF THE CHEST. 

Vesiculotympanitic : Lung with increased proportion 

of air. 
Amphoric : Empty cavity with tense walls. 
Cracked-pot : Cavity w T ith flaccid walls. 



AUSCULTATION. 

The act of listening is termed in medicine auscul- 
tation, and the diagnostic value of this procedure 
rests upon knowing what should be heard in health 
as well as what are the variations incident to disease ; 
wherefore it may be inferred that the study of aus- 
cultation of the thorax includes a consideration not 
only of the abnormal but also of the normal sounds. 
Moreover, it follows that the course to be pursued 
with this method should not differ from the one 
taken wdth percussion. 

There are two ways of listening to the chest, 
namely, to place the ear upon it, which constitutes 
immediate auscultation ; and to listen through some 
conducting substance, which is called mediate auscul- 
tation. Of these methods the first is preferable in 
the observation of respiration, and the second in the 
detection of heart sounds and murmurs. In fact, 
with the heart, mediate auscultation is at times indis- 
pensable. 



PHYSICAL METHODS OF DIAGNOSIS. 



59 



Instruments to convey sound from the body are 
termed stethoscopes. iSow, a sound is a vibration 





Sinde inflexible Flexible double Steth- 
Stethoscope. oscope. 



Double Stethoscope, 



60 EXPLORATION OF THE CHEST. 

that is appreciable by the ear, and a stethoscope is a 
medium for the direct transmission of these vibra- 
tions from the chest of the person examined to the 
eai of the examiner. Some stethoscopes are flexible 
while others are inflexible, and of these two kinds 
there are many varieties. An inflexible stethoscope 
■usually consists of a slender cylindrical stem six or 
eight inches in length, with a small disk at one end, 
the aural extremity, and a slight expansion at the 
other end, the thoracic extremity ; and since elasticity 
is essential to the molecular vibration of this medium, 
and the greater the elasticity the greater the facility 
of transmission, the choice of material should be 
guided by this qualification. Among hard substances 
either wood or iron best fulfills such a requirement, 
and the wood must be cut in the direction of its fiber. 
We have diverse flexible stethoscopes, including both 
single and double instruments. One form of binaural 
stethoscope is composed of a rubber tube for each ear. 
kept in place by a curved wire spring and inserted in 
a hollow, somewhat funnel-shaped objective extremity. 
Another form has a similar thoracic end-piece seven 
eighths of an inch in diameter by three in length, and 
a couple of short flexible tubes which are connected 
by a mortise-joint with two metal tubes curved to fit 
each ear and held in position by a spring concealed in 



PHYSICAL METHODS OF DIAGNOSIS. 61 

the hinge that joins them. In this instrument the 
wave-sounds that enter the tube are prevented from 
expanding, hence they reach both ears with undimin- 
ished energy. A flexible binaural stethoscope has 
much to recommend it. The pliability enables the 
examiner to assume an easy attitude during ausculta- 
tion, which is very desirable, and at the same time to 
see that the thoracic extremity of the instrument is 
properly placed, which is absolutely essential. Per- 
fect adjustment of the auricular ends to the external 
auditory canals at least shuts out all extraneous noises, 
if it does not actually increase the perception of sound. 
Some authorities maintain that there is no good rea- 
son why two ears should hear better than one ; yet, in 
spite of that, a double stethoscope seems to magnify 
the sound. It is believed by others that there is an 
additional function in the combined use of two ears, 
locating the direction whence sound-waves proceed. 
Eoosa says that most of those who have lost the use 
of one ear complain that it is very difficult to decide 
where sound comes from ; and the writer has discov- 
ered, in testing the relative merits of a number of 
stethoscopes, what appears to be a demonstration of 
this dual function of the ears. The steps of the ex- 
periment are as follows : Let the observer take a bin- 
aural stethoscope, with arms made of soft rubber 



62 EXPLORATION OF THE CHEST. 

tubing, and listen to the beating of a watch. The 
sound now will be referred by him to where the 
watch is. If, however, he close one of the tubes by 
squeezing it, the tick of the watch will then be not 
only shut out from this ear, but also transferred from 
the locality of the watch to the other ear 5 and the per- 
ception of direction lost. Next, a change of pressure 
to the other tube carries the sound back, not to the 
watch, but to the former ear. Finally, by a removal 
of the obstruction from the tube, the beating is heard 
again in the direction of the watch on which rests the 
objective end of the stethoscope. This holds, like- 
wise, when one listens to the heart, and the applica- 
tion of so interesting a fact to auscultation is the part 
it possibly takes in rendering a double more accu- 
rate than a single stethoscope. Whether it more 
sharply defines the position of the sound or in reality 
increases the intensity, the binaural instrument, by 
engaging both ears, improves hearing and seemingly 
augments the sound. That it does magnify sound, 
moreover, is commonly urged as its greatest objec- 
tion But a stethoscope is seldom required in listen- 
ing to respiration, and, when thus employed, due al- 
lowance can be made for such alteration. Further- 
more, loud heart-murmurs are easily heard, yet these 
do not always indicate grave lesions ; while exceed- 



PHYSICAL METHODS OF DIAGXOSIS. 63 

ingly soft murmurs are difficult to hear, but some- 
times accompany serious disease. Hence the very 
fact that sound is exaggerated by these stethoscopes 
facilitates the detection of murmurs that might be 
otherwise overlooked, and renders diagnosis possible 
where it was previously impracticable. 

In the choice of a binaural stethoscope the student 
should be careful to select one that fits his ears close- 
ly, thereby excluding external sounds, but still not so 
tightly as to cause pain, for this would divert atten- 
tion from the sensation of hearing. The small ob- 
jective end should be not more than seven eighths of 
an inch in diameter, and the spring or elastic joining 
the arms not too stiff Always adjust the instrument 
with the concavity of the metallic tubes in front, so 
that the earpieces shall enter in the direction of the 
auditory canals, which is inward and forward. Place 
the thoracic end evenly and firmly upon the chest, 
and hold the stethoscope between the thumb and one 
finger. 

For auscultation the positions of the person ex- 
amined are those taken during percussion; the exam- 
iner should so place himself as to be free from all con- 
straint ; and, though mediate auscultation must be 
made upon the bare skin, yet the exposure need not 
be extensive. 



64 EXPLORATION OF THE CHEST. 

The same precautions sliould be observed in list- 
ening as when percussing. Compare similar regions 
repeatedly, and never fail to include the whole chest 
in the examination, for a want of thoroughness is 
quite as disastrous as a lack of skill. It is not uncom- 
mon to mistake friction of the stethoscope upon a 
hairy chest for signs of thoracic disease ; also the 
throat- sounds or noises made by many persons while 
breathing are liable to a misinterpretation. By di 
recting a patient to open his mouth during the exami- 
nation, noisy respiration often can be obviated, and, 
moreover, it is an ingenious device for the prevention 
of annoying garrulity. Shaving the hair will remove 
the cause of the first-mentioned complication. Fur- 
thermore, the respiratory signs fail in their develop- 
ment where the breathing is. shallow ; and when this 
is the case, a few enforced coughs will be followed of 
necessity by a deep breath and the respiratory sounds. 
Lastly, some effort is requisite to concentrate the at- 
tention upon auscultation, particularly with begin- 
.ners, and the consequent fatigue soon dulls the sense. 
A nerve-center becomes exhausted just as overworked 
muscles do, and when this stage is reached, as it often 
is through constant listening, the auscultator should 
temporarily refrain from further work. 

Auscultatory Signs in Health. — Respiratory sounds 



PHYSICAL METHODS OF DIAGNOSIS. 65 

are those of inspiration and of expiration. They are 
characterized by quality, pitch, intensity, duration, 
and rhythm. This last refers to the regular suc- 
cession of the two acts which comprise respiration; 
the others have been duly explained in connection 
with percussion. 

Now, certain types of breathing can be heard in 
healthy persons just as many kinds of percussion res- 
onance have been observed. These are vesicular, 
bronchial, and broncho-vesicular respiration. 

An alteration in the character of the breathing 
and likewise a change of position include some of the 
important signs of disease, so that one must become 
familiar with the typical respiration of different lo- 
calities. 

Take, therefore, a person under the same condi- 
tions indicated for percussion and perform immediate 
auscultation in the region on the left,, between the 
clavicle and the third rib. Here is heard a prolonged, 
low-pitched, soft inspiration, followed without interval 
by a short, low-pitched, soft expiratory sound. This 
is vesicular or pulmonary breathing. In the corre- 
sponding region on the right, vesicular respiration is 
somewhat higher in pitch and expiration more pro- 
longed than upon the left ; and as the examiner ap- 
proaches the trachea and larger bronchi either in front 
4 



6Q EXPLORATION OF THE CHEST. 

or behind, breathing becomes less vesicular and ap- 
proximates bronchial respiration. 

Inspiration in some instances may be loud and in 
others quite feeble, while expiration is not infre- 
quently absent. The intensity of the breathing is 
great during childhood, variable in middle life, and 
diminishes with old age. Children have what is 
called puerile, old persons senile respiration. Vesicu- 
lar breathing, then, subject to these modifications, is 
heard in the chest wherever there is normal lung- 
tissue. 

If the listener will now place his stethoscope over 
the trachea, a long inspiratory sound can be heard, 
high-pitched and intense, like a current of air passing 
through a tube. This is followed after a short in- 
terval by expiration which has the same tubular quali- 
ty, but a higher pitch, greater intensity, and longer 
duration. This is known as bronchial or tubular 
breathing. 

As its name implies, broncho-vesicular respiration 
partakes of the characteristics of two kinds of breath- 
ing, and proportionately as one or the other predomi- 
nates. Here inspiration is usually shortened in dura- 
tion, raised in pitch, and of increased intensity, while, 
if not absent, expiration after a pause is prolonged 
and higher pitched, as well as of greater intensity than 



PHYSICAL METHODS OF DIAGNOSIS. 67 

in the first act. In the normal chest broncho-vesicu- 
lar breathing can be heard where a thin layer of lung 
overlaps the bronchi, as between the scajDulse behind 
and also near the large tubes in front. 

Cavernous and amphoric breathing are two forms 
of respiration not found in health. The first is a 
hollow, low-pitched sound, with a longer and lower- 
pitched expiration than inspiration; the second is but 
a modification of the first, and has a musical quality 
more or less resembling the sound generated by blow- 
ing into the mouth of an empty flask. 

Auscultatory Signs in Disease. — The normal vesicu- 
lar respiration undergoes sundry alterations in disease. 
It may be either exaggerated or diminished, or else 
suppressed. Under some circumstances the rhythm 
becomes divided, under others interrupted, while ex- 
piration is often prolonged ; and in the place of vesic- 
ular breathing broncho-vesicular or bronchial breath- 
ing may be found. 

An exaggerated breathing is heard over that part 
doing extra wort for a disabled lung wherein, for in- 
stance, there is an extensive consolidation or where 
the luug is compressed by a large effusion. 

A diminished breathing occurs where a moderate 
fluid effusion or a plastic exudation exists, and also in 
some conditions of emphysema and of phthisis. 



68 EXPLORATION OF THE CHEST. 

The suppression or absence of vesicular breathing 
indicates an extensive effusion of fluid or of air in 
the pleural cavity, and complete obstruction of a 
bronchus, as well as certain states of phthisis and of 
emphysema. 

What we term interrupted respiration is a break- 
ing of the rhythm into little puffs, and is chiefly in- 
spiratory. This may be caused by pleurodynia, by 
intercostal neuralgia, and is sometimes heard in an 
apparently normal chest. Such breathing, known 
also as cog-wheel respiration, becomes significant only 
when confined to the apex of a lung, for under these 
circumstances, especially if associated with dullness, 
it is one of the signs of incipient phthisis. 

Divided respiration, an interval between the first 
and second acts, is found with bronchial breathing, 
and also in emphysema. 

Prolonged expiration occurs in many cases of em- 
physema and of phthisis ; the pitch remains low in 
the former, and rises in the latter. It must be re- 
membered that expiration is prolonged and low- 
pitched in emphysema, and prolonged but liigh- 
pitched in phthisis. 

Bronchial or tubular breathing, a description of 
which has been given, is heard over hepatized lung, 
as in pneumonia, over well-marked consolidation in 



PHYSICAL METHODS OF DIAGNOSIS. 69 

phthisis, and over compressed lung. From the filling 
up of the air - vesicles, sound-waves are no longer 
diverted into a multitude of lateral paths, as in the 
normal lung, and thereby almost dissipated, but ex- 
tend, on the contrary, by successive reflections 
through the bronchial tubes, from the trachea to the 
surface, and thence to the ear; so that, instead of 
the diffuse, soft, breezy murmur of vesicular respira- 
tion, tubular breathing is heard over consolidated 
lung, with little if any loss of intensity, very much as 
sound-waves are reflected through a speaking-tube, or 
the air-pipes of a binaural stethoscope. 

Broncho-vesicular respiration is found in disease 
where consolidation, or where compression of the 
lung, is not extensive enough to produce bronchial 
breathing, as in the early stage of phthisis, or when 
there is a small intrapleural effusion. 

Cavernous breathing pertains chiefly to excava- 
tions in phthisis with easily collapsing walls ; it is 
sometimes heard where the lung has not gone beyond 
consolidation. 

Amphoric respiration occurs both in phthisis and 
pneumothorax ; in phthisis over large cavities with 
tense walls, in pneumothorax if there be unobstructed 
bronchial communication. 



70 EXPLORATION OF THE CHEST. 

RECAPITULATIOX. 
Rhythm — Regular Succession of the Respiratory Acts. 
Interrupted rhythm : Slight deposit in lung. 
Divided rhythm : Want of elasticity in lung. 
Prolonged expiration: Want of elasticity in lung. 

Breathing. 
Vesicular: Uncomplicated lung. 
Bronchial: Consolidated lung; compressed lung. 
Broncho- vesicular : Moderate consolidation. 
Broncho-vesicular ; Moderate compression. 
Cavernous : Flaccid cavity-walls. 
Amphoric : Tense cavity-walls. 
Exaggerated : Vicarious respiration. 
Diminished: Plastic exudation, want of elasticity. 
Absent: Fluid, air. 

Adventitious Signs. — In addition to these changes 
of character in the normal respiration, which were 
shown to be an evidence of an altered condition, 
there are some new or adventitious sounds that serve 
a similar purpose. 

There is but one way to become familiar with 
such sounds, and this is to embrace every opportunity 
of listening to them. But they are nowhere audible 
in a healthy person, and therefore, unlike the former 



PHYSICAL METHODS OF DIAGNOSIS. 71 

signs, can be studied only in the patient. Some prep- 
aration, however, is necessary for their recognition, 
and also for a correct interpretation of their signifi- 
cance. 

Now, in view of the fact that all knowledge is 
more or less relative, an absolute grouping of these 
signs is not to be expected. Still, nearly every design 
will be fulfilled by the following classification, name- 
ly : harsh, sibilant, and sonorous breathing ; crepitant, 
subcrepitant, bubbling, tracheal, gurgling, and splash- 
ing rales ; metallic tinkle, and friction. 

By harsh breathing is meant that the soft, breezy 
respiration has become rough through a variation in 
the bronchial mucous membrane that falls short of de- 
veloping sibilant or sonorous breathing, but which, if 
carried a little further, would result in them. This 
kind of breathing is common in bronchitis, and espe- 
cially in the chronic form of the malady. 

Sibilant breathing, also termed sibilant rales, is a 
high-pitched, whistling sonnd that conveys the idea of 
dryness rather than of moisture. This noise is not 
constant, and can usually be heard during both acts 
of respiration, yet at times it is confined to inspira- 
tion. 

Sonorous breathing, likewise called rales, is a low- 
pitched, dry, snoring sound of variable intensity. It 



72 



EXPLORATION" OF THE CHEST. 



is present during both acts of respiration, is incon- 
stant, and not infrequently is restricted to expiration. 




mv 



4 




Diagram illustrating sibilant and sonorous rales. 

Sibilant breathing has its origin in the smaller, sono- 
rous in the larger bronchi, from a contraction in their 
caliber, either by spasm or pressure, or else by viscid 
secretions. The expiration is prolonged with both 
kinds of breathing. These sounds are heard in asth- 
ma, and in some cases of acute and in many cases of 
chronic bronchitis. 



PHYSICAL METHODS OF DIAGNOSIS. 73 

Crepitant rales are fine, dry, crackling sounds, an 
example of which may be obtained by rubbing the 
objective end of an adjusted stethoscope against a 
hairy chest. Rales of this nature are heard only 
during or toward the end of inspiration, and are su- 
perficial and rapidly evolved. They are frequently 
inaudible, because not developed unless the patient is 
made to breathe deeply. The sound probably origi- 
nates in the pleura, for crepitation is not heard until 
the two surfaces of this membrane move one upon 
the other ; it ceases when movement becomes impos- 
sible, and commonly returns with returning pulmo- 
nary mobility. Another explanation of the source of 
these rales is based upon the assumption that the 
walls of the air-cells are stuck together, by a viscid 
secretion during expiration, and torn apart by each 
inspiration, which thereby causes the crepitation. 
These rales are nearly, if not quite, characteristic of 
pneumonia, yet certain conditions of the pleura, simi- 
lar to what obtain in that affection, may give rise to 
just such crackling. 

Subcrepitant r&les are fine, bubbling sounds, gen- 
erated in the smaller bronchi by air passing to and fro 
through fluid. They are distinguished from crepitant 
rales by their liquid quality, and by their occurrence 
with both acts of respiration. These rales are found 



74 



EXPLORATION OF THE CHEST. 



on each side of the chest, at the lower part of the 
lung, in capillary bronchitis, and in pulmonary cede- 




Diagram illustrating large and small bubbling rales, 

ma. "When limited to the apex, they may be one of 
the signs of phthisis. Lastly, they accompany resolv- 
ing pneumonia, and sometimes follow an haemoptysis, 
Bubbling rales are developed by air passing back- 
ward and forward through fluid in the larger bronchi, 
and hence differ but in degree from subcrepitant 
rales. 



PHYSICAL METHODS OF DIAGNOSIS. 75 

Still coarser rales are produced after the same 
manner in the trachea, and from it take their name — 
tracheal rales. The bubbling rales are heard in bron- 
chitis,- in phthisis, and during the latter stage of pneu- 
monia, while tracheal rales are peculiar to comatose 
and to moribund states. 

Gurgling rales sound like the coarse, irregular, 
noisy flow of liquid from a bottle, and are the result 
of the passage of air through fluid into cavities. 
These rales occur in the excavations of phthisis and 
in bronchial dilatations, whose secretions impede the 
entrance of air. Loud clicks at intervals may be 
heard in connection with gurgles, and are supposed 
to be the bursting of bubbles in the vomicae. 

Splashing rales are sounds stirred up by shaking a 
patient's chest wherein there are both air and liquid. 
This operation, which is termed succussion, is per- 
formed with the ear directly upon the chest of the 
person examined, and a hand upon each shoulder. 
Such rales are practically restricted to hydropneumo- 
thorax; but it is within the range of possibility to 
mistake the splashing of fluid and air in the stomach 
for the signs of this disease. 

Metallic tinkle, which is defined by its name, is a 
tinkling sound that is heard with irregular recurrence 
in hydropneumothorax, and more especially when 



76 EXPLORATION OF THE CHEST. 

there is a bronchial communication ; and, while it is 
almost confined to this malady, it may possibly be 
audible in a large excavation of phthisis; and, too, 
like the splashing rale, it can be transmitted from the 
stomach to the chest. 

Friction is a grazing, rubbing, or crackling sound, 
according to the circumstances of its development. 
If the student, while listening, will slide the object- 
ive end of his stethoscope from side to side along the 
chest, he will find an example of one variety of this 
noise. It is commonly a to-and-fro rubbing, but it 
may be limited to inspiration. And there are times 
when this last is quite indistinguishable from the 
crepitation of pneumonia. Under these conditions, 
the history, symptoms, and other signs must deter- 
mine its meaning, rather than a difference in the qual- 
ity of the sound. Friction is heard in dry pleurisy, 
in the early stage of pleurisy with effusion, and near 
the beginning of pericarditis. 

The rubbing returns after the reabsorption of 
fluid, when it may be styled secondary friction, and 
often remains a long period. A pericardial is distin- 
guished from a pleuritic friction by the time and 
place in which it occurs. The first is synchronous 
with cardiac pulsation, the second with respiration ; 
pleuritic friction takes place in the pulmonary area, 



PHYSICAL METHODS OF DIAGNOSIS. V7 

usually at the side, pericardial friction in the re- 
gion of the heart, often near its base. Isow and 
then the action of the heart sets up an intra- 
pleural friction, which is recognized as such with 
difficulty. 

Finally, all extraneous sounds must be carefully 
eliminated during an examination. Among those 
most likely to happea are rubbing of the ear, the 
stethoscope, the clothes, and of fractured ribs, as well 
as the vibrations of moving bones and muscles, and 
also unusual noises carried to the ear through the 
chest from the throat or stomach, 

RECAPITULATION OF ADVENTITIOUS SIGNS. 
Breathing. 
Harsh: Moderate thickening of bronchial mucous 
membrane. 

Bales. 

Sibilant : Contraction of small bronchi. 
Sonorous: Contraction of large bronchi. 
Crepitant : Slight exudation on pleura. 
Subcrepitant : Air and fluid in small bronchi. 
Bubbling: Air and fluid in large bronchi. 
Tracheal: Air and fluid in trachea. 
Gurgling: Air and fluid in excavation. 
Clicks: Air and fluid in excavation. 



78 EXPLORATION OF THE CHEST. 

Splashing: Air and fluid in pleural cavity. 
Metallic tinkle : Air and fluid in pleural cavity. 

Friction, 
Exudation in pleura. 
Exudation in pericardium. 

Vocal Resonance. — The voice transmitted through 
the chest to the ear receives the name of vocal reso- 
nance ; and there is a typical normal vocal resonance 
for different parts of the chest, just as a characteristic 
respiratory murmur was found. Generally speaking, 
this resonance is an ill- defined vibration, somewhat 
low in pitch, and of rather moderate intensity. But, 
as the listener approaches the larger bronchi, either in 
front or behind, the intensity increases, until over 
these tubes, and especially along the trachea, near the 
source of the vibration, the sound becomes unpleasantly 
loud, and closely borders upon articulation. As with 
fremitus, this resonance is greater upon the right than 
the left side, and just below the right clavicle than 
elsewhere. Likewise it is diminished by an overly- 
ing deposit of fat, and by a feeble or even high- 
pitched voice. Seeing that the low-pitched tones are 
transmitted with greatest velocity, it is not improb- 
able that they are more distinctly audible for this rea- 
son. At all events, vocal resonance is best developed 



PHYSICAL METHODS OF DIAGNOSIS. 79 

by causing the patient to count one, two, three, in as 
deep a tone as possible. 

Now, vocal resonance may be increased, dimin- 
ished, or entirely suppressed by disease ; and, like the 
respiration, it may assume a bronchial quality, which 
is termed bronchophony. Moreover, there are two 
modifications of this normal vocal resonance, called, 
respectively, amphoric voice and segophony ; the last 
is a tremulous, high-pitched sound, thought to re- 
semble the bleating of a goat, the first a musical tone, 
such as vibrates with the voice in an empty flash. 

"When not only the voice, but also distinct articu- 
lation, is conveyed by way of the chest to the ear, it 
is known as pectoriloquy. 

A similar transmission of whispered words is 
termed whispering pectoriloquy. 

The voice, in a whisper, heard without well-de- 
fined articulation, is called cavernous whisper. 

Increased vocal resonance is found, usually, over 
consolidated and over condensed lung-substance. 

Diminished vocal resonance is the result of pleu- 
ral effusion or of plastic exudation. 

Absence of vocal resonance may be one of the 
signs of an intrapleural effusion, yet this vibration of 
the voice is not infrequently present even when the 
chest is quite full of fluid. 



80 EXPLORATION OF THE CHEST. 

Bronchophony appears in pneumonia, and over 
vomicse, and where the lung is compressed by fluid. 

Amphoric voice, like amphoric breathing, is heard 
in hydropneumothorax, and over large excavations 
with tense walls in phthisis. 

iEgophony is occasionally developed over com- 
pressed lung just below or at the level of a pleural 
effusion. 

Pectoriloquy may take place under two conditions 
— one that of solidification, the other from excavation 
of lung-tissue. As a consequence of this it is evident 
that the assistance of other signs will be required to 
determine its meaning. 

Whispering pectoriloquy occurs under like cir- 
cumstances. 

Cavernous whisper is one of the signs of an exca- 
vation. 

Finally, all these signs depend upon a knowledge 
of local variations and a comparison of similar re- 
gions for their utility. 

RECAPITULATION OF VOCAL RESOXAXCE. 

Normal: Yoice through normal chest. 
Bronchophony : Voice through consolidation. 
Amphoric: Voice in a cavity. 
.zEgophony : Voice in compressed lung. 



PHYSICAL METHODS OF DIAGNOSIS. 81 

Pectoriloquy : Articulate voice in cavity ; in consoli- 
dation. 

Whispering pectoriloquy : Whispered articulation in 
cavity; in consolidation. 

Cavernous whisper : Ill-defined articulation in cavity. 



DIAGNOSIS BY PHYSICAL SIGNS OF DIS- 
EASES OF THE LUNGS. 

Inasmuch as actual disease varies often very much 
from the typical instances given in books, a considera- 
tion of the several physical signs, such as the previous 
pages have embraced, is of decided importance. 

"We found that an isolated sign may be of in- 
definite value, but joined with others it has a definite 
share in shaping diagnosis ; that a sign may be nor- 
mal in one and become abnormal in another place ; 
and that most signs depend upon comparison for their 
significance. Hence a knowledge of the general prin- 
ciples of physical diagnosis is requisite for an intelli- 
gent study of thoracic affections. 

BRONCHITIS. 

Acute Catarrhal Bronchitis. — In most instances 
acute bronchitis runs its course with no abnormal 
physical manifestations. This is due either to the 




THORACIC CAVITY.— LUNG DRAWN FORWARD. BRONCHI AND PUL- 
MONARY YESSELS EXPOSED. VIEW FROM THE RIGHT SIDE 
(HIRSCHFELD). 

1, trachea; 2, oesophagus; 3, arteria innominata ; 4, subclavian artery; 5, 
superior vena cava ; 6, right azygos vein ; 7, thoracic aorta ; 8, right 
pneumogastric nerve ; 9, thoracic duct. 



ACUTE CATARRHAL BROXCHITIS. 83 

small extent of the lesion or the large size of the tubes 
involved. The diagnosis of such cases rests upon the 
history and symptoms, supported by the negative re- 
sults of the physical exploration. Here we exclude 
pneumonia, pleurisy, and phthisis, by the absence of 
a combination of signs that might indicate one or 
more of these maladies. Even when the inflamma- 
tion reaches the medium-sized tubes, in idiopathic 
bronchitis, there may be no physical signs; but, if 
present, the signs are a slight increase in the fre- 
quency of the breathing; and, as the affection ad- 
vances, a thrill is sometimes communicated to the 
hand. There is little if any fever, 102° F. being 
about the average maximum elevation of temperature. 
On percussion, as a rule, there is no dullness. Early 
in the disease, upon auscultation, the intensity of the 
vesicular murmur is increased ; later it is diminished, 
or wholly obscured by rales. An obstruction of a 
bronchus may cause a circumscribed suppression of 
the respiratory sounds, but the patient by coughing 
can usually effect their reappearance. The breathing, 
more especially in chronic bronchitis, may approach 
the character of sonorous — i. e., become what is 
termed harsh respiration — and thus continue through- 
out the disease ; yet, now and then, there are sibilant 
and sonorous rales in the dry stage, with the addition 



84 EXPLORATION OF THE CHEST. 

cf large and small bubbling rales in the stage of secre- 
tion. These rales are variable in amount, heard over 
each lung, and may disappear, temporarily, from one 
or both sides. Expiration is prolonged. Yocal res- 
onance is unaltered. 

It is neither the intensity nor quality, nor yet the 
stability of the rales, so much as the amount of heart- 
failure and dyspnoea, that indicates how seriously the 
patient is affected. 

Chronic Catarrhal Bronchitis. — The physical evi- 
dences of chronic are nearly those of acute bronchitis. 
We may have simply harsh respiration, or else the 
same lack of positive signs. Still, sibilant and sono- 
rous breathing are more often present in chronic than 
the acute form of this disease. And when emphysema 
complicates chronic bronchitis, as it frequently does, 
the signs are modified by that affection. Then in- 
spection shows more or less permanent expansion of 
the chest with deficient respiratory play, and at the 
same time considerable prominence of the auxiliary 
breathing muscles. On palpation the fremitus will 
be diminished, or at least unchanged. On percussion, 
instead of normal there may be vesiculotympanitic 
resonance. On auscultation the vesicular murmur is 
usually obscured by bronchial rales, and expiration 
prolonged ; yet all respiratory sounds may be de- 



DIAGNOSIS BY PHYSICAL SIGNS, 85 

creased and even absent from the lung wherein there 
is much emphysema. Yocal resonance is either un- 
altered or diminished. Fever is commonly absent. 

A bronchitis that affects but one of the lungs is 
generally symptomatic ; and, confined to the apex, it 
is very often one of the signs of phthisis. Finally, 
the duration rather than the character of the signs 
distinguishes chronic from acute bronchitis. 

SUMMARY : SIGN'S OF BRONCHITIS. 

Inspection : Negative. 
Palpation : Ehonchal fremitus. 
Mensuration : Negative. 
Calormetation : Moderate fever. 
Percussion : Negative. 

Auscultation : Sibilant and sonorous breathing ; large 
and small bubbling rales. 

Bronchiectasis. — As dilatation of a bronchus is 
sometimes found with chronic bronchitis, it must 
be distinguished from a similar expansion occurring 
in phthisis with pulmonary excavation. Now, simple 
dilatation gives rise to the auscultatory signs of a 
cavity ; but, on the other hand, there is seldom much 
abnormal dullness, and though there may be some 
dullness from an accumulated secretion, and possibly 



86 EXPLORATION OF THE CHEST. 

from compression of the adjacent lung, yet it does 
not precede the signs of excavation as in phthisis, and 
it is perceptibly diminished by evacuating the con- 
tents of the bronchial cavity. Moreover, in the last 
stage of phthisis dullness generally surrounds the 
vomicae, whereas in dilated bronchi the resonance 
around the cavity is frequently normal. Then, too, 
the physical signs are almost stationary in the latter 
affection, while in phthisis they are always or nearly 
always progressive. 

Fever is absent during a greater part of the time 
with dilatation of the bronchi, but with phthisis it 
is present through most of the progress of the dis- 
ease. 

Furthermore, the disproportion in bronchiectasis 
between the general condition of the patient and the 
local manifestations is very noticeable ; and, lastly, a 
careful inquiry into the history and symptoms will 
lead to a correct interpretation of the existing phys- 
ical signs. 

Acute Capillary Bronchitis. — When the inflamma- 
tion extends to the smaller bronchi or originates 
in them, either of which is very liable to happen 
in children and in old persons, there are additional 
signs of bronchitis to those already given. 

It is seen by inspection that breathing is rapid ? 



ACUTE CAPILLARY BRONCHITIS. 87 

that all the auxiliary muscles are brought into use, 
and that, difficult in any attitude, it is quite impossi- 
ble to breathe while lying down. Moreover, with ob- 
struction enough to cause an extensive collapse of the 
lobules, instead of the customary expansion of the 
chest, there will be a falling in at each inspiratory 
effort. The face is flushed, or in extreme cases livid 
and bedewed with sweat, and the lips and finger-tips 
are cyanotic. 

Palpation detects an increase in the labored re- 
spiratory acts to forty, sixty, and even eighty in the 
minute. 

The temperature of capillary bronchitis ranges 
from 101° to 103° F., and the fever often subsides 
with the progress of the malady. 

Upon percussion the resonance is normal or may 
be vesiculotympanitic, with possibly some dullness 
at the lower portion of the lung behind. Where the 
upper lobes become emphysematous, the resonance 
there is vesiculotympanitic. Where the lower lobes 
are collapsed or consolidated, there the percussion 
note is dull. But wherever neither emphysema nor 
collapse nor yet consolidation exists, the resonance is 
normal. 

Upon auscultation the vesicular murmur may be 
diminished or quite absent. It is sometimes dimin- 



88 EXPLORATION OF THE CHEST. 

ished and at other times absent where there is vesicu- 
lar emphysema. It is absent from the plugging of a 
bronchus. It is always somewhat diminished by the 
disease and frequently smothered by the rales. "When 
the affection is- general, sibilant breathing may be 
heard throughout the chest, accompanied or followed 
by subcrepitant rales, which are bilateral. These sub- 
erepitant rales are present in every case of capillary 
bronchitis, and they not uncommonly mask the aus- 
cultatory signs of a complicating lobular pneumonia. 

summary: sigxs of capillary bronchitis. 

Inspection : Orthopnoea, dyspnoea, cyanosis. 
Palpation : Respiration forty to eighty. 
Mensuration : Negative. 

Calormetation : Temperature, 101° to 103'5° F. 
Percussion : Normal, vesiculotympanitic. 
Auscultation : Sibilant, subcrepitant rales. 

Croupous Bronchitis. — The physical evidences of 
croupous or fibrous bronchitis chiefly depend upon 
the presence of membranes, which are formed in the 
bronchi. This variety of bronchitis is exceedingly 
rare, yet all students that have once seen the pe- 
culiar sputa will have no difficulty in recognizing the 
disease. 



ASTHMA. 89 

Just previous to the expulsion of a cast there is 
usually some dyspnoea. The vesicular murmur is di- 
minished and even suppressed over a portion of the 
lung when a large bronchus is obstructed. In some 
instances a rustling or flapping sound is heard, to- 
gether with the rales of catarrhal bronchitis, should 
this coexist. 

There may be dullness, from a temporary col- 
lapse of lung-substance. 

Fever accompanies acute but not chronic forms 
of this disease. 

However, it is upon the appearance of the branch- 
like or cylindrical tube-casts, which were described 
under the head of sputa, that the diagnosis of croup- 
ous bronchitis rests. 

All kinds of bronchitis are distinguished from 
pneumonia and from phthisis mainly by the absence 
of dullness ; and if associated with these affections it 
is diagnosticated by the presence of bronchial rales 
in addition to the signs of the other malady. 

ASTHMA. 

Spasms oi the bronchi occur primarily or follow 

emphysema or else bronchitis. The physical signs 

of asthma are those developed during a paroxysm. 
5 



90 EXPLORATION OF THE CHEST. 

It is seen upon inspection that the respiration is 
slow and laborious, with dyspnoea marked in expira- 
tion. 

On palpation, vocal fremitus is normal. On per- 
cussion, resonance is either normal or vesiculo- tym- 
panitic. 

On auscultation, sibilant and sonorous breathing 
are revealed, widely diffused throughout the chest, 
of decided intensity, and chiefly expiratory. More- 
over, considerable wheezing is audible at a distance 
from the patient, and with the subsidence of the 
spasm bubbling rales are heard ; but when the par- 
oxysm is secondary to bronchitis, it is not unusual 
for these rales to exist from the commencement. 
The vesicular murmur, which is jerky in rhythm, 
may have its intensity increased or diminished. Yo- 
cal resonance is not changed. The temperature is 
unaltered. 

"With the relaxation of idiopathic bronchial spasm 
there is a return of the normal respiratory murmur ; 
but in symptomatic asthma the signs of emphysema 
or bronchitis continue and become more distinct. 

There is aphonia in laryngitis, with stridor rather 
than wheezing, and the dyspnoea is mainly inspira- 
tory. On the other hand, there is neither aphonia 
nor stridor in asthma, but wheezing and expiratory 



HAEMOPTYSIS. 91 

dyspnoea. While in oedema of the glottis there is 
no aphonia, yet, as in laryngitis, the dyspnoea is in- 
spiratory; and, above all, though present in asthma, 
sibilant and sonorous breathing are absent both in 
oedema of the glottis and laryngitis. 

SU3MAKY : SIGHTS OF ASTHMA. 

Inspection: Respiration slow, labored, gasping. 

Palpation : Ehonchal fremitus. 

Mensuration : Negative. 

Calormetation : No fever. 

Percussion : Resonance normal, vesiculotympanitic. 

Auscultation : Sibilant, sonorous breathing, wheezing. 



HAEMOPTYSIS. 

For the diagnosis of bronchorrhagia we chiefly 
depend upon inspection. Hence, should a patient 
expectorate bright-red, frothy blood, in all proba- 
bility it would come from the bronchi, providing 
there is neither buccal nor naso-pharyngeal haemor- 
rhage. The trickling of blood from the pharynx into 
the throat, whence expelled by a cough, now and 
then proves a cause of alarm to the patient, and of 
mistake to the physician. 

While it is true that haemoptysis is usually fol- 



92 EXPLORATION OF THE CHEST. 

lowed by large and small bubbling rales in the in- 
volved region, nevertheless physical exploration, at 
this time, should be performed gingerly, if at all, for 
the risks attending a disturbance of the patient are 
greater than the value of the acquired information. 
But later, when an examination can be made with 
safety, it is well, if possible, to find the source of the 
bleeding. 

Although pulmonary haemorrhage, so called, is 
commonly due to phthisis, heart disease, and to aneu- 
rism, with a frequency in the order enumerated, yet 
the flow of blood may be bronchial in its origin, and 
bronchial only. But, still, phthisis, or a predispo- 
sition to phthisis, is most often the condition in which 
there is spitting of blood, and this may precede all 
other appreciable signs. With a copious haemorrhage 
the temperature usually declines. 

Finally, if the bleeding takes place in the stom- 
ach, the blood thrown up can be distinguished from 
that which comes from the bronchi by its color, con- 
sistency, and mode of exit. It is dark, mixed w T ith 
food, and vomited ; whereas blood from the lung is 
light red, frothy, without ingesta, and wells from the 
throat with scarcely a cough. 



PULMONARY EMPHYSEMA. 93 

PULMONARY EMPHYSEMA. 

In emphysema both lungs are involved, as a rale, 
but not to a like extent. The upper border of each 
lung may be affected, or the upper in one and the 
lower border in the other. 

There is a senile emphysema in which contraction 
rather than expansion of the lung takes place. Here, 
too, a dilatation of the air-cell occurs, yet the whole 
lung is decreased in bulk from an atrophy of the 
pulmonary tissue. 

By inspection, in emphysema, the breathing is 
seen to be labored and prolonged in expiration. 
There is a drooping of the shoulders ; the muscles 
of the neck stand out prominently ; and the contour 
of the chest is more or less altered, by an expansion 
just below the clavicles, or below the clavicle of one 
side and the nipple of the other. Less commonly 
there is an arching forward of the sternum, an antero- 
posterior curvature of the dorsal spine, and, in fine, a 
general expansion of the thorax that is suggestive of 
a barrel, and which is therefore appropriately termed 
barrel-shape. 

On the other hand, in senile emphysema, there is 
neither this general expansion nor any local bulging 
of the thorax. 



91 EXPLORATION OF THE CHEST. 

The only visible cardiac impulse in the first-men- 
tioned variety of this malady is confined to the epi- 
gastric region. 

Upon mensuration it may be found that the cir- 
cumference of the lower part of the chest becomes 
even less during inspiration, while, higher, there is 
practically no expansion. In fact, the chest- wall seems 
to be lifted up bodily, rather than expanded, and 
breathing is almost wholly diaphragmatic. 

On palpation, though vocal fremitus is often unal- 
tered, it may be either diminished or absent, while in 
senile emphysema the fremitus is not infrequently ex- 
aggerated. 

By percussion, in distinctive cases, the quality of 
the note is vesiculotympanitic, yet in many instances 
it is simply pulmonary, or but slightly intensified res- 
onance. 

A marked distention of one side may render the 
other dull by comparison, when in reality there is no 
dullness. 

The area of cardiac flatness and dullness disap- 
pears with great expansion of the lung, and this organ 
may extend so low as to obliterate the dullness as well 
as flatness of the liver. 

Finally, there is no difference, in emphysema, be- 
tween resonance on full expiration and that on full 



PULMONARY EMPHYSEMA. 95 

inspiration, and this is shown by respiratory per- 
cussion. 

Upon auscultation over the emphysematous por- 
tion of the lung, the breathing is diminished or sup- 
pressed, or else, what is more common, inspiration is 
either deferred or absent, and expiration is prolonged 
and of low pitch. Thus the natural ratio of the two 
respiratory acts becomes inverted ; nay, the expira- 
tory may be many times the length of the inspiratory 
act. Also, fine bronchial rales are heard where bron- 
chitis coexists. 

Yocal resonance, in this affection, is not to be re- 
lied upon, for it may be absent, or normal, or even 
increased. 

The sounds of the heart are partially or wholly 
obscured in all but the tricuspid area. 

As the disease is unattended by fever, a rise in the 
temperature would indicate some intercurrent affection. 

The physical signs of emphysema could be mis- 
taken only for those of pneumothorax. 

Now, the resonance in the latter is always tympa- 
nitic, and, moreover, one-sided, whereas it is seldom 
if ever purely tympanitic in the former, but rather 
vesiculotympanitic, and on both sides. Furthermore, 
the respiration, if heard, in pneumothorax is am- 
phoric, in emphysema not ; and, too, the difference 



96 EXPLORATION OF THE CHEST. 

in the history and symptoms of the two maladies is 
very clearly defined. 

summary: sigxs of emphysema. 

Inspection : Breathing slow and labored. 
Palpation : Fremitus diminished ; unaltered. 
Mensuration: Slight if any expansion. 
Calormetation : No fever. 

Percussion : Resonance normal ; vesiculotympanitic. 
Auscultation : Respiration diminished ; absent ; or, 
prolonged low-pitched expiration. 



PULMONARY (EDEMA. 

In pulmonary oedema the serum is usually diffused 
throughout the lung, but, when the fluid is abundant, 
much of it gravitates to the dependent parts of the 
organ. 

By inspection, the frequency of the respiration is 
found to be increased, and with this there is consid- 
erable dyspnoea. 

On palpation, the vocal fremitus in one instance 
may be exaggerated, and in another diminished ; 
therefore, it is of little positive value in the diagnosis 
of this affection. 

Upon percussion, with a great deal of oedema, 



PULMONARY (EDEMA. 97 

tliere is dullness, and it is most noticeable behind, at 
the lower portion of the lung. 

Through auscultation it is learned that the vesic- 
ular murmur is either absent, or at least quite feeble. 
And subcrepitant rales, often very fine, are heard 
over the involved region. Vocal resonance is no more 
reliable than vocal fremitus. There is no fever at- 
tending this condition. 

From capillary bronchitis, pulmonary oedema dif- 
fers in having slight dullness and no fever. And the 
absence of bronchial breathing, of fever, and of well- 
marked dullness would exclude inflammation of the 
lungs. Moreover, oedema is bilateral, while, as a rule 
pneumonia is unilateral. The sputa of the former are 
copious, frothy, and watery ; of the latter scanty, vis- 
cid, and of a characteristic color. Lastly, it is a help 
to know that oedema of the lungs is commonly asso- 
ciated with dropsy in the body elsewhere. 

SUMMARY : SIGNS OP (EDEMA. 

Inspection: Rapid, difficult breathing. 
Palpation : Fremitus diminished. 
Mensuration : Negative. 
Calormetation : No fever. 
Percussion : Some dullness. 
Auscultation : Bilateral subcrepitant rales. 



98 EXPLORATION" OF THE CHEST. 

PNEUMONIA. 

An inflammation of the pulmonary tissue does 
not necessarily involve an entire lobe, and scarcely 
ever the whole lung. It begins at some one spot, 
usually the lower lobe, and thence rapidly extends, 
oftentimes irrespective of the intervening fissure. 

The malady is termed single or double pneumonia, 
as one or both lungs are affected ; and when the in- 
flammation fails to reach the surface of the lung, it 
is known as central pneumonia. 

For convenience, the disease is divided into three 
stages, each with its special signs. One part, how- 
ever, may have arrived at the second, while another 
is progressing toward this stage. And now and then, 
owing to a speedy hepatization, the first appreciable 
evidences of pneumonia are those of the second stage 
— consolidation. 

The three stages, with respect to the physical 
signs, are congestion, solidification, and resolution. 

First Stage.— Congestion. 

Inspection. — In the first stage of pneumonia there 
is seen rapid breathing, of a panting nature, and, 
withal, some restriction in the respiratory play of the 
affected side. A view also of the sputum is of assist- 



PNEUMONIA. 99 

ance, for, with a limited central pneumonia, this and 
the fever may be the only physical manifestations of 
the disease. First, the patient spits a frothy mucus; 
then, less easily, a sticky, translucent material, which 
adheres to the receptacle. The color of the sputum 
is amber, orange, or brick-dust, according to the 
amount of blood w r ith which it is tinged, for blood 
is diffused through the expectoration, and not usually 
in streaks. Such matter is called rusty sputa. Some- 
times the material coughed up is quite fluid, and 
shades into a prune-juice color, which is considered 
a bad omen. Children, it must be remembered, have 
pneumonia often without expectoration. 

Palpation. — By counting the respirations, they 
are found to have increased to forty, and even eighty, 
a minute ; and, while there is commonly an exaggera- 
tion of vocal fremitus on the affected side, in some 
instances this is not perceptible. 

Calormetation. — The temperature rises quickly to 
103°, 104 , or 105°, and even to 106° F., and there 
remains for nearly twenty-four hours, after which 
there is a daily morning remission, followed by an 
evening exacerbation. As a fair elevation, 104° F. 
might be taken, and a moderately high fever seems 
to be rather favorable than otherwise. At all events, 
the student is cautioned against too much alarm at 



100 EXPLORATION OF THE CHEST. 

very temporary flights of the index, and is likewise 
reminded of the proneness of children to high tem- 
peratures. On the other hand, old persons may be 
in most critical conditions of pneumonia with no 
fever. 

Percussion, — Over the involved area there is a 
rise in pitch toward the end of this stage, which 
amounts to moderate dullness, providing the disease 
extends to the surface of the lung. 

Auscultation. — In the affected portion of the 
lung the intensity of the vesicular murmur varies. 
It may be exaggerated, but it is often diminished. 

A multitude of crepitant rales are soon heard, 
which are fine, crackling sounds, developed at or near 
the close of an inspiration. But, unless the patient 
is made to breathe deeply, these rales will be over- 
looked ; and when consolidation takes place rapidly, 
they are not produced. Yocal resonance is increased. 

Second Stage. — Solidification. 

Inspection. — The respiratory action of the chest- 
wall is now chiefly confined to the unaffected side, 
where it is magnified and still rapid. Actual dysp- 
noea, however, is not always present. 

Palpation. — Over the affected portion of the 
lung, in most instances, vocal fremitus is increased. 



PNEUMONIA. 101 

But in some there is either no alteration or the vibra- 
tion is actually diminished. 

Calormetation. — There is a continuation of the 
high thermometrical range, and while the highest 




Diagram showing, from above downward, the three stages, congestion, 
solidification, and resolution of pneumonia. 

point may be reached early in this stage, sometimes 
the fever is at its maximum elevation just before a 
crisis, which is commonly later. 

Percussion. — Well-defined dullness over the area 
of consolidation usually marks this stage, while over 
non-hepatized lung the resonance is intensified, or 
possibly vesiculo-tympanitic. 

But percussion signs depend upon the situation 



102 EXPLORATION OF THE CHEST. 

and the extent of the solidification, for central pneu- 
monia may afford only slight dullness, or none what- 
ever; whereas, if the whole lung is involved, there 
will be flatness rather than dullness. Moreover, there 
may be tympanitic resonance either from a close 
proximity of the consolidation to the stomach, dis- 
tended by gas, or because of the nearness of the 
pneumonia to a large bronchus. 

Now, between the tympanitic resonance of pneu- 
monia and that of pneumothorax there is this differ- 
ence, namely, an unmistakable feeling of resistance 
in the former, which is not felt in the latter, upon 
percussion. 

In some instances, furthermore, a cracked -pot 
sound can be detected in pneumonia, and these are 
mainly when percussing over a large bronchus, 
whence the air is driven as from an excavation. 

Auscultation. — Where consolidation is, there, as 
a rule, bronchial breathing is heard, and likewise 
bronchophony, and frequently whispering pectorilo- 
quy- 

Still, these signs may possibly fail, from an over- 
lying pleuritic exudation or from an obstruction to 
a large bronchus. In the latter instance the breath- 
ing may be restored by a series of forced coughs. 

But pnenmonia occurs at times with some dull- 



PNEUMONIA. 103 

ness over a circumscribed area where there is no 
bronchial breathing ; not, in this case, from plugging 
of a bronchus, but on account of the feebleness of 
the respiration. Here a forced cough will almost 
invariably develop a bronchial puff, yet the bronchial 
breathing is not permanently restored. 

The peculiar vibration of the voice, known as 
bronchophony, also may be developed where bron- 
chial breathing can not, and thus prove a very useful 
sign. 

Finally, upon the unaffected side of the chest 
there is usually an exaggerated or puerile respiration. 

Third Stage. — Resolution. 

There are no physical signs by which gray can 
be distinguished from red hepatization; hence, we 
pass to the manifestations of resolution. 

The clearing up takes place step by step, and its 
progress is attended by physical signs of the receding 
deposit. 

Inspection. — With resolution the normal respira- 
tory action of the chest is resumed, and the sputa 
become yellow in color and abundant. 

Palpation. — Yocal fremitus is lessened in in- 
tensity. 

Calormetation. — The temperature returns to the 



104 EXPLORATION OF THE CHEST. 

normal, or falls to the subnormal, either suddenly or 
by degrees — more often, however, in the former 
manner. And it will be observed that the panting 
respiration terminates with the decline of the fever, 
before resolution has made much progress. Thus 
rapid breathing seems to depend not upon the extent 
of the consolidation alone. 

Percussion. — The decrease of dullness is quite 
gradual, and a slight amount remains a long time. 

Auscultation. — From bronchial breathing there 
is a return to broncho-vesicular, and thence to pul- 
monary respiration, with the disappearance of bron- 
chophony and of increased vocal resonance. And 
associated with these changes crepitant and suberepi- 
tant rales are heard, the latter of which predominate. 
Moreover, there may be large, bubbling rales as well. 

The physical signs of pneumonia in the very old 
are often obscure, because of the rigidity of the 
chest-wall and the senile changes in the lung itself. 
Fever, too, is either slight or absent, and there may 
be no dyspnoea, not much acceleration of the breath- 
ing, and, what is more, little if any expectoration e 
In fact, bronchophony, or else the bronchial pufi 
before mentioned, may be the only physical mani- 
festation of the disease. 

Purulent Infiltration. — "When, instead of resolution, 



PXEUUONIA. 105 

purulent infiltration occurs, the temperature remains 
high, dullness and bronchial breathing continue, and, 
in addition, high-pitched, gurgling rales are heard, 
while the expectoration becomes both profuse and 
purulent. 

Abscess. — A pulmonary abscess can be detected, 
after a bronchial communication has been established, 
by the physical signs of an excavation, which are 
given in connection with those of phthisis. 

Lobular Pneumonia. — The physical signs of lobu- 
lar are mainly those of lobar pneumonia, but, as a 
rule, they are confined to small areas ; and, excej)t 
a large number of contiguous lobules are affected, 
these signs are obscured by the physical manifesta- 
tions of the bronchitis, which the pneumonia usually 
complicates. For this reason fine subcrepitant rales 
are more often heard than crepitant rales, and dull- 
ness is not easily made out. 

In this disease the temperature rises less suddenly 
than in lobar pneumonia, is more irregular in its 
course, and more gradual in its decline. 

SUMMARY : SIGXS OF PXEUMOXIA. 

Inspection : Panting, rapid respiration ; rusty sputa. 
Palpation : Breathing forty to eighty ; fremitus in- 
creased. 



106 EXPLORATION OF THE CHEST. 

Mensuration : ^Negative. 

Calormetation : Temperature 103° to 105° F. 

Percussion : Dullness — 1st, slight ; 2d, complete ; 3d, 
decreasing. 

Auscultation : 1st, crepitant rales ; 2d, bronchial 
breathing and bronchophony; 3d, broncho-ve- 
sicular breathing, crepitant, subcrepitant, and 
bubbling rales. 



PLEURISY. 

The products of an inflammation of the pleura 
are fibrin, serum, and pus ; now fibrin, then serum 
with fibrin, and then again fibrin, serum, and pus. 
Moreover, there is a resulting formation of new con- 
nective tissue with adhesions or at least thickening 
of the pleura. 

As a rule, these inflammations are confined to one 
side of the chest. 

Where there is an exudation of fibrin alone, it is 
commonly circumscribed, and the disease is called 
dry pleurisy ; and if the exudation is followed by a 
large effusion of serum, the disease is termed sub- 
acute pleurisy. But when the exudation of fibrin is 
attended by an effusion of pus as well as serum, then 
the malady is known as empyema. 



PLEUEISY. 107 

Hence it follows that there are three phases of 
the inflammation to consider ; namely, acute pleurisy, 
subacute pleurisy, and empyema. 

The signs of a collection of serum embrace those 
of purulent effusion, and there is but one method by 
which the nature of the fluid can surely be deter- 
mined, to wit, the withdrawal of a specimen for in- 
spection. Therefore, we shall study the physical evi- 
dences of fibrinous exudation, fluid effusion, absorp- 
tion, and adhesion, in the order named, and dwell, 
in passing, upon the manner of drawing out some of 
the contents of the pleural cavity. 

Fibrinous Exudation. — The signs of acute pleu- 
risy that are seen upon inspection are mainly those 
caused by the all-absorbing pain, and this is usu- 
ally located at the lower part of the affected side 
where there is greatest pulmonary mobility. The 
patient is found doubled over toward this side, which 
he grasps to stay the movement of the ribs and thus 
lessen his suffering. He breathes with difficulty in 
a jerky, catching, rapid manner and superficially, for 
a deep breath fills out the lung and thereby intensifies 
his pain. Moreover, from a like motive he endeavors 
to suppress his cough, which is short, dry, and ex- 
tremely painful ; consequently, the customary respira- 
tory action of the diseased side is considerably restricted. 



108 EXPLORATION OF THE CHEST. 

AYith the advance of the malady a friction vibra- 
tion may be perceptible on palpation, while at the 
same time the vocal fremitus decreases. 

An irregular range of temperature is shown by 
calormetation that rarely exceeds 103° F., seldom 
reaches 101° F., and often falls short of the fever- 
mark. 

On percussion, the resonance rises in pitch with 
the exudation of fibrin to well-defined dullness where 
there is very much plastic material. 

On auscultation, the respiratory murmur is both 
weak in intensity and jerky in rhythm ; but the most 
prominent sign that forces itself upon the ear is one 
of the various forms of friction ; and while this fric- 
tion may accompany either the first or second or 
each respiratory act, it is more often audible with 
inspiration and at the lower part of the chest, where 
the excursion of the lung is most extensive. Fur- 
ther, for just this reason, friction now and then es- 
capes observation as the sufferer seeks to control the 
movements of the lung in order to keep the pleural 
surfaces apart. Hence, if the suspected friction be 
inaudible, it is a good plan to ask the patient to take 
a deep breath or to cough, the latter of which will 
be followed of necessity by the desired inspiration. 

To distinguish acute pleurisy from the first stage 



PLEURISY. 109 

of pneumonia, we keep in mind the low range of 
temperature of the former as compared with the 
high range of the latter, the friction of pleurisy in- 
stead of the crepitant rale of pneumonia, and the 
characteristic sputa of the last-named in place of no 
expectoration in the first-named affection. 

There are two conditions that closely simulate 
dry pleurisy, namely, neuralgia of the intercostal 
neiwes, and rheumatism of the intercostal muscles. 
In neuralgia there are some painful points along the 
course of the neiwe, while in rheumatism there is 
wide-spread tenderness. Moreover, pressure aggra- 
yates the tenderness of the one and alleyiates the 
pain of the other, whereas in pleurisy both super- 
ficial pain and tenderness are less common and less 
affected by external pressure. Furthermore, though 
feyer may be associated with neuralgia and with 
pleurodynia, yet it oftener accompanies inflammation 
of the pleura, and, aboye all, friction appears in 
pleurisy, while it is neyer heard as a result of in- 
tercostal neuralgia nor of 'rheumatism. 

Serous Effusion. — As fluid collects in the chest 
the opposing surfaces of the pleura are gradually 
separated, and, if the effusion is sufficiently exten- 
siye, friction disappears, to return, howeyer, with 
the reabsorption of the liquid; consequently, with 



110 EXPLORATION OF THE CHEST. 

these altered conditions there is a corresponding 
change in the physical manifestations. 

Inspection. — Our attention is drawn, not only to 
the lack of motion upon the affected side, but also, if 
the effusion is abundant, to the enlargement of this 
side, and at the same time to the increased respira- 
tory play of the unaffected portion of the chest. 
Still, this alteration in the size of the chest is 
not so common in adults as in children, for the 
elasticity of the thorax diminishes with advancing 
years. 

While the breathing is somewhat increased in fre- 
quency by an effusion, it is neither the panting seen 
in pneumonia nor the dyspnoea that attends acute 
pleurisy. In fact, the patient is usually not conscious 
of much difficulty with the breath, except upon exer- 
tion. By closer inspection we may find that the in- 
tercostal spaces bulge, or at least remain stationary, 
with inspiration. 

Where a large effusion occupies the right pleural 
cavity, the heart is displaced to the left, and, contra- 
riwise, the organ is pushed to the right by an effusion 
in the left pleural cavity. 

Palpation. — The position and force of the cardiac 
impulse, however, are better determined by the hand 
than by the eye, and likewise the frequency of the 



PLEURISY. HI 

respiration, which varies with an effusion from twenty 
to thirty a minute. 

Vocal fremitus disappears in the region of the 
fluid, and, on the other hand, is sometimes exagger- 
ated above the effusion, over the compressed lung. 

This absence of fremitus where there is fluid is a 
very constant rule to which there are but few ex- 
ceptions. 

Mensuration. — Though upon forced expiration 
the semi - circumference of th'e affected side often 
measures from one half to two and even three inches 
more than the other, yet quite an amount of fluid may 
gather at the expense of the viscera, without percep- 
tible enlargement of the thorax. 

Calormetation. — While the thermometer may in- 
dicate 100°, 101°, or 102° F., and even a greater 
elevation of temperature, still, in quite a number of 
instances, there will be no fever. 

Percussion. — From below up, as far as the fluid 
extends, there is flatness, but a change in the level of 
this flatness, by altering the patient's position, is not 
so common in pleuritis as with passive effusions. 

The line of flatness takes something of a curve, 
with its lowest point near the spinal column and its 
highest in the axillary line, whence it descends to- 
ward the sternum. Nevertheless, adhesions modify 



112 EXPLORATION OF THE CHEST. 

this line, and large effusions quite obliterate the 
curve. 

In addition to the .flat sound, there is a sense of 
resistance communicated to the hand, in percussing, 
which is very significant of the presence of fluid. 

As we pass from the effusion to the compressed 
lung, the flatness changes to dullness ; and this tran- 
sition is best appreciated after causing the patient to 
take several deep inspirations. But in some few in- 
stances the resonance is vesiculotympanitic instead of 
dull over the displaced lung, and the unaffected side 
is thereby rendered dull by comparison. Now, this 
vesiculo-tympanitic resonance, which occurs above an 
effusion, is thought by some writers to depend upon 
dilatation of the air-cells from a permanent expansion 
of the chest. It seems quite as probable, however, 
that by a certain pressure of fluid, just short of pro- 
ducing collapse, the volume of the lung is contracted, 
so that the air of the bronchi, surrounded by this 
partly apneumatized lung, gives a sound on percus- 
sion that results in a modified tympanitic or, in other 
words, vesiculo-tympanitic resonance ; and when the 
pressure passes beyond this limit, the air-vesicles and 
possibly the bronchi collapse, and then well-marked 
dullness is developed. 

Auscultation. — The auscultatory signs of an effu- 



PLEURISY. 



113 



sion depend upon the acoustic law that " sound- waves 
are transferred from air to liquids or to solid bodies 




Diagram showing the right pleural cavity filled with fluid 



with great difficulty." In consequence of this, the 
respiratory murmur is either inaudible or, at most, 
very faintly heard through the fluid ; and the sound, 
if perceptible, is that of muffled bronchial rather than 
vesicular respiration. This is best appreciated by 
listening to both sides of the chest ; and, indeed, com- 
parison is very essential in all methods of physical ex- 
ploration. 

With children, bronchial breathing is heard 
through fluid somewhat more clearly than with 



114: EXPLORATION OF THE CHEST. 

grown persons ; and, too, there are examples even 
in adults where bronchial respiration can be distinctly 
heard ; but this does not invalidate the rule, for the 
lung under these circumstances is pressed toward the 
back, and there bound by adhesions. "When such is 
the case, let the examiner carry his ear in the direction 
of the axillary line, and the sound almost invariably 
decreases and finally becomes lost upon reaching this 
locality. The axillary line is a most important point 
in which to percuss as well as listen in many thoracic 
diseases. 

Vocal resonance, though absent below the level of 
the fluid in a number of instances, is not infrequently 
present, and present, too, where vocal fremitus is sup- 
pressed. Furthermore, at or near the level of the 
effusion a bleating sound, segophony, is now and then 
audible ; while above the fluid, in the compressed 
lung, there is either broncho-vesicular, bronchial, or 
else, possibly, cavernous breathing; and upon the 
unaffected side there may be, owing to vicarious 
work, what is called puerile respiration. 

It is necessary to decide between a collection of 
fluid caused by pleuritis and one the result of a pas- 
sive effusion. 

In the first place, the history and symptoms are 
different. There is, for instance, no pain attending 



PLEURISY. 115 

the latter, and it is commonly associated with dropsy 
in other parts of the body. The hydrothorax has for 
its remote cause an organic lesion of the heart or the 
kidneys, and, as a rule, is bilateral ; whereas it is the 
exception for pleurisy to occur in both sides. A pas- 
sive effusion is not preceded by friction ; and, more- 
over, fever is always absent. Lastly, the fluid of 
hydrothorax more easily changes its position* with the 
movements of the patient than that of pleurisy, and 
thereby alters the level of flatness. 

To distinguish an effusion of pleurisy from the 
solidification of pneumonia, we must likewise consider 
the history and symptoms, as well as the physical 
signs. 

The invasion of pneumonia is signalized by a de- 
cided rigor ; that of pleurisy by chilliness, without 
much shivering. Pain may or may not be prominent 
in both affections. 

An effusion usually gravitates to the lower part of 
the chest ; consolidation may take place at any point 
in the lung. 

In pleurisy there is immobility of the affected 
side, with expansion ; in pneumonia there is some im- 
mobility, but no expansion. 

The sputa of the last-named are characteristic, 
those of the first-named affection not. 



116 EXPLORATION OF THE CHEST. 

Fremitus is absent in pleurisy, while in pneumo- 
nia it is not only present but exaggerated. 

The respirations are from forty to eighty in the 
one, and from twenty to thirty a minute in the other. 

The half circumference is increased by an effusion 
and not modified by consolidation. 

The temperature ranges from 100° to 103° F. 
in pleurisy, while in pneumonia it commonly lies 
between 102° and 105° F. 

Where there is fluid there is flatness ; hepatization 
gives dullness. 

Upon auscultation vocal resonance and the vesicu- 
lar murmur are absent in pleurisy, but in pneumo- 
nia both bronchial breathing and bronchophony are 
heard. 

Purulent Effusion. — An inflammation of the 
pleura may be followed by a pouring out of pus at 
once, or after a time the serum may be changed to 
pus. Such a condition is known as empyema, and 
also as pyothorax. 

Now, if there is fluid in the pleural cavity, the 
physical signs will be the same, whether it is pas, 
blood, or serum. Therefore, the student has but to 
turn back to u Fluid Effusion" for the physical mani- 
festations of this disease. 

With signs of an effusion in the pleural cavity, 



PLEURISY. 



117 



there is good reason for suspecting pus, should re- 
peated rigors and sweats occur, as well as a higher 
range of temperature than ordinarily obtains in sub- 
acute pleurisy. But positive evidence of the nature 
of the effusion can be gained only by drawing out 
some of the fluid for inspection. And though this 
may be accomplished by means of a hypodermatic 
syringe, yet an aspirator is preferable, for the ex- 




Aspirator. 

hausting power of the latter instrument is much the 
stronger, and the caliber of its needles better suited 
to the purpose. 

A good position for the patient during this op- 
eration is to sit sidewise upon a chair, and a con- 
venient attitude for the operator is to kneel upon the 



US EXPLORATION OF THE CHEST. 

floor. The place where the needle should be intro- 
duced is either the fifth, sixth, or seventh intercostal 
space, just to the outer side of the scapular line. Let 
the operator for a moment firmly press his thumb 
into the space selected, and then insert the needle 
where he has made the depression. The entrance 
should be effected nearer the lower than the upper 
part of the intercostal space, and the instrument 
thrust not deeper than one inch, to escape the in- 
tercostal vessels in the first, and to avoid reaching the 
lung, or possibly the diaphragm, in the second in- 
stance. If the needle is pushed through the fluid into 
the lung, not only is that organ wounded, but the ob- 
ject of the procedure defeated. 

And, with all these precautions, in view of a pos- 
sible injury to the expanding lung, it is perhaps ad- 
visable to use a small trocar and cannula, now made 
to fit the aspirator, rather than the sharp needle 
which usually accompanies that instrument. 

Absorption. — As the fluid recedes, the fremitus 
slowly returns, flatness disappears from above down- 
ward to the lower part of the chest, and vesicular 
respiration is again heard, but in diminished inten- 
sity. With this comes a return of the friction, 
which often lasts for a considerable time. And, too, 
at the lower part of the chest, because of the thick- 



PLEURISY. 119 

ened pleura, flatness may continue for an indefinite 
period. 

A contraction of the chest does not usually fol- 
low acute pleurisy, but it frequently succeeds the 
subacute form, when, as shown by mensuration, there 
is a decrease in the semi-circumference of the affected 
side, toward which the heart is then drawn. 

It is now and then a difficult matter for many 
examiners to determine whether flatness, in a given 
case, is due to fluid or to the remains of an old pleu- 
risy ; but, in the latter instance, if the half-circum- 
ference is not decreased, it certainly will not be in- 
creased. Moreover, the heart will be drawn toward, 
rather than pushed from, the affected side ; and, fur- 
thermore, the breathing will be indistinctly heard 
through the area of flatness, upon very careful and 
repeated auscultatory exploration ; but, however faint, 
it will be vesicular, instead of muffled bronchial res- 
piration. 

Adhesion. — With the absorption of a sero-purulent 
effusion, there may be an adhesion of the costal and 
pulmonary pleura, and attachments may also follow 
a plastic exudation, or form in the very commence- 
ment of the disease. Under these circumstances there 
is considerable restriction of the respiratory play of 
the affected side ; the half-circumference is dimin- 



120 EXPLOKATION OF THE CHEST. 

ished, the heart is drawn toward the contraction, vo- 
cal fremitus is either decreased or absent, and there is 
dullness or flatness, in proportion to the amount of 
new connective tissue. Lastly, the respiratory mur- 
mur is suppressed, or, at least, feeble ; while here and 
there friction-sounds remain audible. 

SFMMAEY : SIGXS OF SUBACUTE PLEURISY. 

Inspection : Marked immobility with expansion ; no 

distinctive sputa. 
Palpation : Yocal fremitus absent ; breathing twenty 

to forty. 
Mensuration : Increased semi-circumference. 
Calormetation : Temperature 100° to 103° F. 
Percussion: Flatness. 
Auscultation : Friction ; absence of vesicular murmur 

and vocal resonance. 

Contrasted with signs of pneumonia : 

Inspection : Slight immobility with no expansion ; 

rapid, panting respiration; characteristic sputa. 
Palpation : Yocal fremitus increased, breathing forty 

to eighty. 
Mensuration : Negative. 
Calormetation : Temperature 102° to 105° F. 
Percussion : Dullness. 



HYDROTHORAX. 121 

Auscultation : Crepitant rales ; bronchial breathing 
and bronchophony. 



HYDROTHORAX. 

A passive effusion in the chest, termed hydrotho- 
rax, is detected by the same physical methods that 
are employed to demonstrate the fluid of pleurisy. 

In the latter, however, the effusion is commonly 
single, whereas in the former condition it is always 
double. But the dropsy of the two sides is not 
equally extensive ; and, unless the chest is full, the 
position of the liquid shifts with the movements of 
the patient more easily than in pleurisy. "With fluid 
on one side, the lateral displacement of the heart is 
much greater than when both sides are affected. 
Moreover, there is no fever in hydro thorax. The 
effusion is not preceded by friction ; it is commonly 
associated with dropsy elsewhere, and is frequently 
the result of disease of the heart or kidneys. 



PNEUMOTHORAX — PNEUMO-HYDROTHORAX — PKETJ- 
MO-PYOTHORAX. 

Air, without liquid, in the pleural cavity is called 
pneumothorax ; with serum, it is termed pneumo- 



122 EXPLOKATION OF THE CHEST. 

hydrothorax ; and with pus, it is known as pneumo- 
pyothorax. 

On inspection, in pneumothorax, there is seen de- 
cided dyspnoea. But, inasmuch as the affected side is 
in a state of permanent expansion, with bulging of 
the intercostal spaces, from this influx of air, the 
respiratory movements are absent from that lo- 
cality. Upon the unaffected side they are dimin- 
ished. Consequently, the breathing is mainly dia- 
phragmatic. 

By palpation the vocal fremitus is found to be 
absent over the volume of air, and the heart moved 
by this gaseous effusion toward the normal side. 

On mensuration, the half-circumference of the 
inflated side of the chest is commonly much increased, 
but it is not impossible for air to occupy the pleural 
cavity at the expense of the viscera alone. 

By percussion, the resonance is tympanitic, where- 
of the pitch is sometimes high and other times low, 
according to the tension of the parietes produced by 
this elastic fluid ; for, the greater the stretching, the 
higher the pitch. 

On the other hand, wherever the lung chances to 
be pressed, or is adherent, there will be dullness ; and 
some thickening of the pleura may also cause dull- 
ness on light percussion ; but with a forcible stroke? 



PNEUMOTHORAX. 



123 



under these circumstances, the tympanitic quality 
usually comes out. 

By auscultation, the vesicular murmur is found 
wanting, but now and then bronchial breathing can 




Diagram showing air and fluid in the right pleural cavity. 

be heard, as from a distance, even where there is no 
fistulous opening ; and when the channel through 
which the air entered the chest remains patent, there 
is well-defined amphoric respiration. Moreover, the 
metallic echo of the voice in the pleural cavity is of 
considerable significance ; or, better, the metallic echo 
of a percussion stroke upon the pleximeter, which, 
however, requires the assistance of a third person. 



124 EXPLORATION OF THE CHEST. 

Meantime, over the compressed lung there is 
bronchial breathing, and in the healthy lung there is 
puerile respiration. 

Now, upon the advent of fluid in the pleural cavi- 
ty, be it serous or purulent, the tympanitic resonance 
gives way to flatness, from below up as far as the 
liquid extends. Then there is tympanitic resonance 
above and flatness below the level of the effusion. 
And here, more particularly, a change in the patient's 
position causes a movement of the fluid that percept- 
ibly alters the level of flatness. 

Yocal fremitus remains absent. There is more or 
less fever associated with pneumo-pyothorax. 

The auscultatory signs continue the same above, 
with the addition of an occasional metallic tinkle, 
while below the level of the effusion there are neither 
voice nor respiratory sounds. But the physical mani- 
festations peculiar to this condition (air and fluid in 
the pleural sac) are splashing rales, developed by suc- 
cussion, a method of investigation described in con- 
nection with auscultation. 

SUMMARY : SIGXS OF AIR AXD FLUID IX PLEURAL SAC. 

Inspection : Immobility, expansion dyspnoea. 
Palpation : Yocal fremitus absent. 
Mensuration : Semi- circumference increased. 



PHTHISIS PULMONALIS. 125 

Calormetation : Possibly fever. 

Percussion : Tympanitic above, flat below. 

Auscultation : Respiratory murmur absent ; or, am- 
phoric breathing above, all sounds absent below ; 
splashing rales. 



PHTHISIS PULMOXALIS. 

Acute Phthisis. — So far as the physical signs are 
concerned, acute phthisis differs from chronic phthisis 
in the quickness with which these signs are devel- 
oped. 

Because of the rapid and extensive hepatization 
that is associated with the tubercular process, this 
malady has been termed pneumonic phthisis ; and, 
moreover, for the same reason, in the commencement 
of the disease, it is now and then mistaken for pneu- 
monia, from a similarity in the signs and symptoms. 

But in acute phthisis the frequency of the respira- 
tions is not so great as in pneumonia ; and, although 
the evening temperature may rise to 104° F. a 
number of times in the course of the affection, still 
it more often fails to reach that mark, and in the 
morning it is commonly not much above 100° F., 
while frequently it falls to 99° or 98*6° F. In 
addition, the crepitant rale is less prominent than a 



126 EXPLORATION OF THE CHEST. 

subcrepitant rale. The dullness on percussion gradu- 
ally changes, in the region of excavation, to amphoric 
or cracked-pot resonance, at the same time that 
bronchial breathing and bronchophony, heard in the 
vicinity of solidified lung, give way to gurgling rales, 
cavernous breathing, and pectoriloquy. 

That the foregoing signs are, in some instances, 
confined to one side of the chest, is explained by the 
occasional post-mortem appearances, namely, miliary 
tubercles scattered throughout both lungs, with con- 
solidation and vomicae in but one lung. 

Chronic Phthisis. — The first stage of phthisis is 
marked by the advance of deposition up to well-de- 
fined consolidation, and the second by a breaking 
down of the necrosed tissue with final excavation. 

As this process begins at the upper part of the 
lung and travels downward, it is near the apex that 
the early signs of these changes become apparent. 

In chronic miliary tuberculosis the little tubercles 
may be so scattered through the lung, or, if confined 
to the apex, so complicated by emphysema, as to 
nearly, if not quite elude detection. 

First Stage. 

Inspection. — There is probably very little about 
the contour of the chest to justify a suspicion of com- 



PHTHISIS PULMONALIS. 127 

mencing phthisis. But early in the disease can be 
seen, upon careful inspection, some restriction of the 
inspiratory expansion at the apex of the affected side, 
and later there is more or less depression in this same 
locality. The lack of motion is more noticeable in 
women than in men, owing to the greater natural 
mobility in the superior costal region of the former. 
An increase in the frequency of the respiratory ac- 
tion is not especially pronounced, except upon exer- 
tion. 

Palpation. — The diminished expansibility of the 
affected side is perhaps best appreciated in supple- 
menting inspection by palpation, while the examiner 
stands behind and enough above the patient to look 
down upon his chest. 

As a rule, the intensity of vocal fremitus increases 
with the consolidation ; but, for reasons given else- 
where, this sign is less serviceable in women than in 
men ; and it always has greater significance upon 
the left than the right side with both sexes, because 
of its habitual predominance in the latter situation. 

The momentary circumscribed superficial eleva- 
tion produced by a smart tap of the finger upon the 
chest, known as "myoidema," is absent in so many 
cases of well-marked phthisis, and, contrariwise, pres- 
ent in such a number of patients where phthisis is 



128 EXPLOEATTON" OF THE CHEST. 

undemonstrable, that the writer is led not to consider 
it a distinctive sign of the malady, but rather a some- 
what frequent coincidence. It seems to be oftenest 
found in the emaciated who have been, heretofore, 
decidedly muscular, and seldom in those suffering 
from wasting disease, be it phthisis or not, whose 
muscular development was never pronounced. 

Calormetation. — Fever is one of the earliest phys- 
ical manifestations of phthisis ; and, although there 
is no thermometrical range peculiar to this malady, 
pyrexia is pretty sure to accompany the advance of 
the disease, and to disappear while it remains station- 
ary. At some period, then, in the twenty-four hours 
fever can be found, and this is usually toward even- 
ing. Moreover, an intermittent moderate elevation 
of temperature indicates a slower progress of the 
lesion than a slight but constant pyrexia, while rapid 
strides may be inferred if the fever continues high ; 
yet death is sometimes preceded by a subnormal tem- 
perature. 

Percussion. — Dullness is found in degrees vary- 
ing with the onward course of this stage, and is best 
developed above the clavicle by a gentle stroke while 
the patient's mouth is open. Upon the clavicle it is 
customary to perform immediate percussion, for here 
the bone takes the place of a pleximeter. 



PHTHISIS PULMOXALIS. 129 

The surest way to render delicate variations of 
tone appreciable is to place the back of the patient 
against a sounding-board, and another available de- 
vice is to practice respiratory percussion at the same 
time. It must be borne in mind, however, that the 
normal pitch is almost always higher at the right 
than at the left apex, and also that it is possible for 
a localized emphysema to hide the signs of tubercle. 

Auscultation. — There are three different phases 
of the respiratory murmur that may obtain at the 
apex in early phthisis : 1. The expiration, either 
with or without the normal inspiration, may be pro- 
longed and of high pitch. 2. The respiration 
may be extremely feeble in this locality. 3. The 
rhythm may be broken into little puffs, known as 
jerky or cog-wheel respiration, whether the pitch be 
high or low. But this jerky rhythm must not be 
confounded with a similar condition sometimes caused 
by the pulsation of the heart against the lung. 

As a rule, the cardiac sounds become accentuated 
in the area of consolidation, and there may be a 
systolic murmur over the subclavian artery. 

Now, when it is taken into account that vocal 
fremitus and vocal resonance are not always reliable 
signs, and further that the breathing is less pul- 
monary in quality at the right than the left apex, it 



130 EXPLORATION OF THE CHEST. 

follows that the changes must be unquestionable on 
that side to be decisive. In fact, there should be 
some of the adventitious signs, of localized bronchitis, 
pleuritis, or parenchymatous inflammation, to insure 
a reasonably certain diagnosis. 

Later in the disease either broncho-vesicular or 
bronchial breathing can be heard, and, if bronchial 
rales are present, they are usually high in pitch. 

Finally, toward the end of this stage, depression, 
with lack of mobility in the affected region, grows 
well marked, but allowance must be made for a cer- 
tain amount of excavation beneath the clavicle, due 
to a waste of tegumentary tissue ; and, though vocal 
fremitus may reach a more decided intensity, it is at 
times obscured by an overlying pleuritic exudation. 

The dullness now becomes unmistakable, and, 
when there happens to be much thickening of the 
pleura, this quality of resonance may be out of all 
proportion to the extent of deposit in the lung. 

A rise in the pitch behind over the scapula is best 
detected by comparing the dullness of one bone with 
that of the other; for dullness is normal in this region, 
and only increased by an underlying consolidation. 

Vocal resonance may be exaggerated, or bron- 
chophony be heard ; and, while the breathing by this 
time is commonly bronchial, it occasionally is inaudi- 



PHTHISIS PULMONALIS. 



131 



ble, from the obstruction of a bronchus by collected 
matter, or on account of the general feebleness of the 




Diagram illustrating chronic phthisis in stage of consolidation on left 
and excavation on right side. 

respiration. Under these circumstances a cough will 
at least develop a transitory bronchial puff in the one, 
or permanently restore the breathing in the other in- 
stance. 

Second Stage. 

In the change from the first to the second stage 
there is softening of the inflammatory products, 
breaking down of the pulmonary tissue, and final 
evacuation of the necrosed substance. 

Now, although there are no positive evidences 



132 EXPLORATION OF THE CHEST. 

of softening until bronchial communication is estab- 
lished, yet, when sharp, crackling, moist rales are 
heard over the affected portion of the lung, small- 
sized vomicae probably exist, and therefore softening 
has taken place. Hence the physical signs of this 
stage are chiefly those of excavation. But a cavity 
must be fairly large before its presence can be con- 
clusively shown. 

Inspection. — The impairment of inspiratory ex- 
pansion, and the depression below the clavicle, in 
many instances remain. But now and then mobility 
seems to be less restricted and depression more 
effaced than hitherto, possibly from the destruction 
of contracting tissue in a large superficial excava- 
tion. 

Palpation. — Vocal fremitus at this stage, though 
variable, is usually increased. 

Percussion. — The resonance depends upon the 
position of the cavity, its size, contents, and the 
nature of the intervening tissue. Over a small ex- 
cavation there will be well-marked dullness, and the 
same holds when a large one is filled with fluid. 
Also, where considerable solidification of the king 
or thickening of the pleura overlies a cavity, there 
will be dullness. A large empty cavity in close 
proximity to the surface of the chest may give tym- 



PHTHISIS PtJLMONALIS. 133 

panitic resonance ; and, if the walls of the vomica 
are flexible, and there is a free channel from the 
cavity to the open mouth, a cracked-pot sound can 
be developed by strong percussion. Finally, light 
strokes often fail to bring out anything but dullness, 
where heavy strokes will elicit tympanitic, amphoric, 
or cracked- pot resonance. 

Auscultation. — A medium-sized cavity may give 
only bronchial breathing, which later becomes cav- 
ernous, hut which meantime is not infrequently a 
mixture of both kinds of respiration. If a collection 
of fluid obstructs the free entry of air, there will be 
gurgling rales. When the fluid is below the open- 
ing, cavernous breathing is audible, and gurgling 
rales if the patient coughs. On the other hand, 
vomicse of considerable size, with tense walls and 
free openings into large bronchi, produce amphoric 
breathing. Metallic tinkling sounds are sometimes 
heard. Lastly, there is whispering pectoriloquy, or, 
what perhaps is more common, cavernous whisper — 
the difference being, if distinction is deemed neces- 
sary, that articulation in the latter is less defined 
than in the former. 

In conclusion, it is important to know that the 
physical signs of a cavity, though absent in front, may 
yet be found in the axilla or the supra-spinatous fossa. 



134 EXPLORATION OF THE CHEST. 

SUMMARY : SIGKS OF CHROXIC PHTHISIS. 

First Stage. 

Inspection : Immobility with depression. 

Palpation : Yocal fremitus increased. 

Mensuration : Negative. 

Calormetation : Fever. 

Percussion : Dullness. 

Auscultation : Long, high-pitched expiration ; breath- 
ing feeble ; cog - wheeled ; adventitious rales ; 
vocal resonance increased. 
Later, bronchial breathing; bronchophony. 

Second Stage. 

Inspection : Immobility ; depression same or less. 

Palpation : Yocal fremitus increased. 

Mensuration : Negative. 

Calormetation : Fever. 

Percussion: Dullness; amphoric; tympanitic; cracked- 
pot. 

Auscultation : Cavernous breathing and whisper ; 
gurgles ; amphoric breathing, pectoriloquy, me- 
tallic echo. 

Acute Miliary Tuberculosis. — A sudden rise in the 
temperature, decided acceleration of the pulse, and 



PHTHISIS PULMONALIS. 135 

marked frequency of the respirations, associated with 
more or less cyanosis of the lips and finger-nails, in 
a patient known to have phthisis, would strongly 
point to the supervention of acute miliary tubercu- 
losis if upon physical exploration no other cause 
could be found for these manifestations. 

The rales of a co-existing bronchitis are practically 
the only physical signs of discrete tubercle in the 
chest. But, as these little bodies are generally lo- 
cated in other organs as well, an ophthalmoscopic ex- 
amination often reveals them in the choroid tunic of 
the eye. 

Acute idiopathic miliary tuberculosis is not in- 
frequently mistaken, and with reason, for typhoid 
fever, owing to their great likeness in appear- 
ance. 

There is a somewhat more abrupt invasion of the 
first-named affection ; it is not so often accompanied 
by diarrhoea, and the course of the fever is attended 
by irregularities — such, for instance, as pronounced 
morning, instead of the customary evening, eleva- 
tions peculiar to typhoid fever. 

Fibroid Phthisis, or Interstitial Pneumonia. — The 
distinguishing features of what is sometimes styled 
fibroid phthisis are those referable to the contraction 
of the lung, and, until such takes place, there is 



136 EXPLORATION OF THE CHEST. 

little foundation for isolating this from other forms 
of phthisis by physical signs. 

When, however, contraction does occur, there is 
a uniform falling-in of the affected side, associated 
with a relative expansion of the normal or less af- 
fected side. The heart is noticeably displaced in the 
direction of the retraction. There is dyspnoea upon 
the slightest exertion. Vocal fremitus may or may 
not be increased ; and the half - circumference of 
the diseased side measures considerably less than that 
of the other. Fever makes its appearance toward 
evening. Dullness, with a marked feeling of resist- 
ance to the fingers on percussion, is wide-spread over 
the affected side, while over the area of expansion 
resonance is intensified, and almost vesiculotympa- 
nitic in quality. Listening reveals puerile respira- 
tion in the last-mentioned region, but bronchial or 
at least broncho-vesicular breathing and bronchial 
rales are heard in the former, together with the vari- 
ous signs of vomicae, when extrusion of necrosed 
tissue has happened. 



PULMONARY GANGRENE. 

A diagnosis of gangrene of the lung chiefly rests 
upon the peculiar fetid breath and sputum of the pa- 



CANCER OF THE LUNG. 137 

tient in whose lung consolidation and possibly excava- 
tion has taken place. 

This sputum is of a dark-brown or dirty-gray 
color, very offensive, and sometimes contains shreds 
of lung-tissue. High fever and considerable dyspnoea 
may attend the disease. 

It is to be distinguished from fetid bronchitis, and 
from phthisis with a passing fetor of the breath and 
sputa. Now, dullness is always absent from bron- 
chitis, and, on the other hand, usually present in gan- 
grene ; and, although a temporary gangrenous odor 
may occur in phthisis, there will have been ante- 
cedent signs of vomicae, whereas in sphacelus of the 
lung the bad smell is usually coincident with the 
first evidences of excavation. 



CANCER OF THE LUNG. 

It is impossible to demonstrate with any certainty 
by physical signs the existence of disseminated can- 
cer of the lung. Where, however, there is a cancer- 
ous growth of considerable magnitude, the manifes- 
tations are less equivocal. 

The new growth may start in the mediastinum, 
spread, but not equally, into both lungs, and in its 
course involve the pericardium ; or, have its origin 



138 EXPLORATION OF THE CHEST. 

upon one side of the chest, and there remain to 
the end. 

Certain forms of cancer cause a contraction of the 
side most affected, but more or less bulging of the 
thorax is the rule, with impairment of inspiratory ex- 
pansion. There is usually dyspnoea, as well as in- 
creased frequency of the respirations. Some displace- 
ment of the heart occurs, and there may be oedema 
and congestion of the head, neck, and arms. The 
blood-stained sputa have the appearance of red-currant 

Vocal fremitus, though variable, is often wanting. 
In measurement the half-circumference of the affected 
side is sometimes much increased. Pyrexia is com- 
monly absent. 

Upon percussion, flatness extends with the tumor, 
and there is dullness beyond if the adjacent lung be- 
comes inflamed. This flatness is attended by so much 
resistance to the fingers, that fluid might be suspected 
were it not for the locality ; for an effusion almost 
invariably gravitates to the bottom of the pleural 
cavity, and anteriorly seldom exceeds the median line. 
Hence, if the resonance is pulmonary below and be- 
hind, while, on the other hand, the flatness reaches 
across the sternum in front, the latter is not due to a 
collection of liquid in the pleural cavity. But should 



CANCER OF THE LUNG. 139 

pleurisy complicate a mediastinal tumor, as it often 
does, the fluid must be drawn off before the graver 
malady can be diagnosticated and the growth out- 
lined. 

Upon listening in the area of flatness, the breath- 
ing is either bronchial or faintly vesicular, or else en- 
tirely suppressed. The signs caused by compression 
of a bronchial tube vary with the amount of the ob- 
struction from sonorous breathing to complete silence. 
Where the lung breaks down and extrusion follows, 
there are evidences peculiar to a cavity. 

Finally, though an intra-thoracic tumor in the 
course of the aorta may simulate an aneurism, still 
the transmitted pulsation lacks the expansile quality 
found in the latter ; and, moreover, the history and 
symptoms of the two affections help to distinguish 
one from the other. 



EXPLORATION OF THE HEART. 

The relative position of the heart to the surface 
of the chest is differently stated, according to the 
circumstances under which observations are made — 
whether, for instance, the specimen is frozen or not 
at the time the measurements are taken. 

But, for practical purposes, it is sufficiently accu- 
rate to consider that the organ, mostly covered by 
lung, lies obliquely in the chest, with its base upward 
and backward to the right, and its apex downward 
and forward to the left. The upper border rises a 
little above the le^el of the sternal insertions of the 
third costal cartilages ; the right border extends about 
an inch to the right of the sternum ; the left border 
nearly reaches the left nipple line; and the lowest 
point of the heart approximates the upper edge of 
the sixth left costal cartilage. 

While the superficial cardiac region, or that un- 
covered by lung, is variously described by different 
writers, it is in fact irregular in shape, of variable size 



EXPLORATION OF THE HEART. 



141 



in diverse persons, and on the whole not of much 
real consequence, for percussion of the heart must 




Heart in situ (Dalton, in Flint, "on the Heart"). «, 6, c. etc., ribs; 
1, 2, 3, etc., intercostal spaces ; vertical line, median line; triangle, 
superficial cardiac region ; x on the fourth rib, nipple. 

include not only this part, which gives flatness, but 
also that beneath the lung, which gives dullness, to be 
of definite utility. 

Although an enlargement of the heart may in- 
crease this area of flatness, a retraction of the left 



142 EXPLORATION OF THE CHEST. 

lung will do the same ; and it is temporarily made 
smaller and larger, alternately, by inspiration and ex- 
piration respectively. 

This region of flatness, however, may extend to 
the limits of the pericardial sac, in which there is an 
effusion ; and, conversely, an emphysematous lung, 
when distended to a great degree, may quite obliter- 
ate the superficial space. 

Arteries. — The arch of the aorta passes obliquely 
upward and forward behind and toward the right 
edge of the sternum, thence to the left and backward 
along the left side of the third and down the left side 
of the fourth dorsal vertebra. At this point the ves- 
sel becomes the thoracic portion of the descending 
aorta, which extends along the left side of the spine, 
then in front, and terminates at the aortic opening of 
the diaphragm. The transverse part of the arch rises 
to within an inch of the suprasternal notch, which in 
some instances it nearly reaches. The pulmonary 
artery is located behind the sternum, from origin to 
bifurcation, beneath the arch of the aorta. 

The arteria innominata ascends slanting from the 
arch of the aorta to the upper margin of the right 
sterno-clavicular articulation. 

Relative Site of the Valves. — The pulmonary valves 
are situated behind the junction of the third left cos- 




THORACIC CAVITY. VIEW OF HEART AND BLOOD-VESSELS 
FROM THE RIGHT SIDE (SAPPEY). 

1, right auricle ; 2, right ventricle ; 3, arch of aorta ; 4, pulmonary ar» 
tery; 5, section of the diaphragm; 6, section of right bronchus ; 
V, right pneumogastric nerve ; 8, arteria innominata ; 9, intercostal 
vessels and nerves. 



EXPLORATION OF THE HEART. 143 

tal cartilage with the sternum ; the aortic, underneath 
the third intercostal space, a little below the pulmo- 
nary, and nearer the median line ; the mitral valve, 
deeply beneath the third intercostal space, and nearly 
an inch to the left of the sternum ; the tricuspid, be- 
hind the sternum, on a level with the fourth costal 
cartilage, and about in the median hue. 

Heart-Sounds, and where heard. — It is important 
that heart-sounds should be disassociated in the stu- 
dent's mind from heart-murmurs. Sounds are nor- 
mal and therefore audible in health, whereas murmurs 
are abnormal, and hence occur only in disease. The 
sounds, to be sure, may be heard both in health and 
disease, but under the latter circumstances they are 
modified in quality. 

Owing to the close proximity of the valves of the 
heart to one another, these sounds are best distin- 
guished at points somewhat removed from their ori- 
gin. Such positions are found in the direction of the 
blood -current, and also where the heart approaches 
the surface of the chest. 

The aortic sounds are carried by the onward flow 
of blood to the second right intercostal space, close to 
the sternum ; the pulmonary to the left edge of this 
bone, in the same relative position. On the other 
hand, the sounds of the mitral valve are conducted by 



144 



EXPLORATION OF THE CHEST. 



the left ventricle to where the apex comes in contact 
with the thorax ; while those of the tricuspid are con- 




Diagram showing the positions for listening to the heart-sounds. A, 
aortic ; P, pulmonary ; T, tricuspid ; M, mitral. 

veyed directly through the right ventricle, at the 
lower part of the sternum. Here are the points of 
maximum intensity, not only of heart-sounds but also, 
as a rule, of valvular murmurs. 



EXPLORATION OF THE HEART. 145 

Now, what is the accepted explanation of the 
mechanism of heart-sounds ? The first sound, which 
is synchronous with the apical impulse, is pro- 
duced by the closure of the auriculo - ventricular 
valves, by contraction of the muscular fibers of the 
heart, and by the impulse of the organ against the 
chest. The second sound is due solely to the sudden 
closure of the aortic and pulmonary valves. First, a 
sound, then a short silence, followed by a second 
sound, and then a longer silence, comprise rhythmic 
cardiac action. Both these sounds are audible at the 
apex, and both are heard also at the base ; but, in 
the former instance, the accent is upon the first, and 
in the latter upon the second sound. 

In order to fully appreciate this cycle of the 
heart's action, let the student for a moment consider 
what is taking place within the organ. While blood 
is being thrown from the right ventricle into the 
pulmonary artery, and from the left ventricle into 
the aorta, the auricles are slowly filling. Then, upon 
closure of the aortic and pulmonary valves, blood 
flows passively into the ventricles ; and, just before 
the first sound of the heart, auricular systole drives 
the remaining blood from the auricles into the ven- 
tricles, which in turn propel it onward, one into the 
pulmonary and the other into the systemic circulation. 



146 



EXPLORATION OF THE CHEST. 



The systolic contraction or wave, if it may be so 
termed, really begins in the great veins at the en- 




Diagram of the four cavities of the heart (Bernard), od, right auricle ; 
vd, right ventricle ; og, left auricle ; vg, left ventricle. The arrows 
indicate the course of the blood. 



trance to the heart, spreads through the organ, and 
passes on into the large arteries. 

Methods of examining the Heart. — The same meth- 
ods serve to explore the heart that are employed in 
examination of the lungs. 

By inspection the point where the apex of the 



EXPLORATION OF THE HEART. 147 

heart strikes the chest is shown, and also, to some 
extent, the nature of the impact. The normal site 
of this pulsation is commonly two inches from the 
sternum in the fifth left intercostal space ; still, it is 
safe to extend these limits to the sixth left rib below, 
and as far as the mammillaiy line. In some in- 
stances, from enlargement of an auricle or retraction 
of the lung, or both combined, there is visible cardiac 
pulsation in the third left intercostal space. And an 
increase in the size of the right ventricle will pro- 
duce a beating in the epigastrium. But neither pulsa- 
tion in this region, nor its absence over the apex, is 
of necessity abnormal. 

There are two or three things that alter the posi- 
tion of the apex which are not included in the cate- 
gory of disease — namely, posture, distention of the 
abdomen, and respiration. First, the apex falls toward 
the side upon which the body rests ; second, it is ele- 
vated by a full stomach, or by the pressure due to 
pregnancy; third, it is depressed by a deep breath- 
all of which must be taken into account at the time 
of examination. But, aside from these, considerable 
displacement may be caused by disease elsewhere than 
in the heart. For instance, an intrapleural effusion 
will push the apex from the affected side, while, on 
the contrary, it is dragged toward the side wherein 



148 EXPLORATION OF THE CHEST. 

there is a retraction of the lung. An enlargement of 
the left lobe of the liver may crowd the apex to the 
left. It is pressed downward to the right, and some- 
times hidden by an extensive pulmonary emphysema. 
There is an apparent but not real elevation of the 
apex in the early part of a pericardial effusion, owing 
to a transference of pulsation to another part of the 
heart. These likewise must be excluded before other 
interpretation is given to a removal of the apex from 
its wonted place. 

Finally, it is carried to the left and downward 
by enlargement of the left ventricle ; to the left, and 
possibly away from the chest-wail, by a similar con- 
dition of the right ventricle ; and downward, as well 
as to the left, by an increase in size of the whole 
organ. Moreover, the displacement is in direct pro- 
portion to the enlargement, and the quality of the 
impulse to the nature of the increase. 

In simple hypertrophy of the left ventricle, the 
apex strikes the chest with more than normal force ; 
in hypertrophy of the right ventricle, the apex ex- 
ceeds the nipple line ; but here the force of impulse 
is transferred to the epigastrium, and comes from the 
affected ventricle. When the walls of both ventri- 
cles are thickened, though the pulsation is strong, 
and there is perceptible heaving of the entire prse- 



EXPLORATION OF THE HEART. 149 

cordia, tlie shape of the heart is altered, and the 
stroke of the apex is not well defined. But in dilata- 
tion the pulsation is weak, diffused, and undulating 
or else quite invisible. Furthermore, there are many 
grades of dilated hypertrophy between these two ex- 
tremes of hypertrophy and dilatation, in which the 
impact is either weak or strong, as one or the other 
predominates. 

Still, these changes in the position and force of 
the apical impulse are determined with far greater 
accuracy by the hand than the eye, and by palpation, 
too, valvular thrill and pericardial friction can be 
appreciated. 

The actual distance between points established by 
other signs is found on mensuration. 

Thermometry helps the examiner to decide be- 
tween acute and chronic heart affections, for the 
latter are usually unaccompanied by fever. 

Percussion. — Inasmuch as enlargement of the 
heart increases the area of the precordial flatness and 
dullness in the direction of the enlargement, percus- 
sion will define the extent of this increase. There- 
fore, it is important to know where percussion can 
be performed w T ith advantage, and also what are the 
limits of normal cardiac resonance. 

The two positions best suited to this purpose lie 



150 EXPLORATION OF THE CHEST. 

respectively one inch to the left of the sternum, in 
the parasternal line, and across the chest, upon a 
level with the fourth rib. Commencing^ then, to 
percuss in the parasternal line from above down- 
ward, there is a rise in pitch that amounts to dull- 
ness at the lower border of the third rib, which 
changes to flatness at the lower edge of the fourth, 
and thus continues into the left hepatic area. Next, 
from without inward, the resonance becomes dull 
just within the nipple line, and so continues to the 
free border of the lung, and thence over the super- 
ficial area of the heart there is flatness as far as the 
sternum. With an increase of the right side of the 
heart, dullness can be made out at the right of the 
sternum by percussing from without toward this bone 
at that same level. But in health the results of per- 
cussion in this region, as well as over the sternum, 
are not altogether satisfactory. Still, having located 
the apex and defined the upper and left borders of 
the heart, the size of the organ can be quite accu- 
rately estimated. 

The region of cardiac flatness does not exceed 
the fourth costal cartilage above, nor the sixth below, 
the parasternal line on the left, nor the left edge of 
the sternum on the right. 

A decrease in the size of the heart is not readily 



EXPLORATION OF THE HEART. 151 

made out, but pulmonary emphysema may so lessen 
the extent of the dullness and flatness of that viscus 
as to convey the impression that atrophy has occurred. 
And, what is more, great distention of the lung will 
mask the signs of an existing enlargement of the 
heart. 

Auscultation. — The sounds and likewise the mur- 
murs of the heart are revealed by auscultation. 

If a stethoscope is placed over the apex, which is 
the mitral area, a dull, prolonged tone is heard, low 
in pitch, and accentuated ; this is followed by a brief 
pause, and then by a short, sharp, high-pitched note, 
that in turn is succeeded by a somewhat extended 
silence. This is the circuit of one cardiac revolution, 
with systole and diastole as heard in the mitral region. 
Upon the adjustment of the instrument to the aortic 
area, close to the sternum in the second right inter- 
costal space, these two sounds are again heard, and 
with rhythm unchanged, but with the accent trans- 
ferred from the first to the second sound. 

Now, though both valves at the base unite in 
the formation of the second sound, and each of the 
auriculo-ventricular valves contributes its share to 
the first, yet these sounds are separable one from 
another. There is more intensity to the click of the 
aortic than the pulmonary valves, notwithstanding 



152 EXPLORATION OF THE CHEST. 

the latter are nearer the surface of the chest than 
the former. And, while the sound of the tricuspid 
valve is higher in pitch than that of the mitral, it 
has decidedly less accentuation. Moreover, there is, 
in many instances, a neutral point between these two 
areas, where the sounds vanish, or at least become 
less distinct, and beyond which they reappear, to be 
again plainly audible. 

Seeing that the first sound of the heart is synchro- 
nous with the impact of the apex against the chest, 
when there happens to be no perceptible shock, this 
sound is determinable, should there be a difficulty in 
its recognition, by placing the fingers upon the carotid 
artery, which also pulsates in synchronism with cardiac 
systole. And the position of the apex can be found, 
under these circumstances, with the stethoscope, by 
noting the seat of greatest intensity in the first sound. 

Now and then in women with large mammae, or 
in very fat persons, it is not easy to map out the 
superficial cardiac space by percussion, but through 
auscultation the borders of the region can be traced 
with facility, by moving the stethoscope along the 
lung in this vicinity while the patient speaks ; for 
vocal resonance will come to an abrupt termination 
at the margin of the lung, which marks the limitation 
of the sought-for place. 



EXPLOKATION OF THE HEAKT. 153 

Modifications of Sounds. — There is a regular inter- 
mission of the first sound of the heart in some persons 
which is not necessarily incompatible with health. In 
others there is a reduplication of the second sound, 
from a lack of simultaneous action of the two sides of 
the organ, which points to an obstruction in the cir- 
culation, and commonly at the mitral valve. 

The first sound is dull and muffled at the apex in 
simple hypertrophy, and is characterized more by a 
throb than a sound ; but with dilated hypertrophy it 
is clear, loud, and far reaching ; while in dilatation 
it is sharp, high pitched, and at the same time very 
weak. Indeed, it is feeble, not only in cardiac dilata- 
tion, but also with fatty degeneration of this organ, 
and, in fact, with all diseases that occasion failure in 
the contractility of the ventricle. And, moreover, a 
feebleness of the valvular sound at the left apex, in 
comparison with that of the right side, may indicate 
a mitral affection. Yet it is well to bear in mind 
pulmonary emphysema as a possible cause of this, 
for the distended lung may both stifle the sound of 
the mitral valve, and render the tricuspid more in- 
tense, through a consequent hypertrophy of the right 
ventricle upon the one, and the covering up of the 
left upon the other hand. 

The second sound at the base is generally intensi- 



154 EXPLORATION OF THE CHEST. 

fled by hypertrophy and weakened by dilatation. It 
is deprived of strength by valvular lesions that 
diminish the quantity of blood in the arterial sys- 
tem, such as mitral stenosis or insufficiency ; and, at 
the same time, as well as from a like cause, the pul- 
monary second sound becomes accentuated through 
augmented pressure in the venous system. Hence, 
though there is always a possibility that the aortic 
second sound, enfeebled by disease, may render the 
pulmonary apparently but not really stronger, yet, 
with this prevision, when there is no disease of the 
lung to account for a persistent accentuation of the 
pulmonary second sound, such a condition may be 
taken as presumptive evidence of a valvular affection, 
and more especially of the mitral orifice e 

Heart-Murmurs. — A heart-murmur is an adventi- 
tious vibration set up within this organ, and some- 
times extending into its immediate outlets, by the 
production of a sonorous rush in the blood-current. 

This is brought about by an abnormal narrowing 
of the canal, through some obstruction, which acceler- 
ates the velocity of the stream, and throws the fluid 
into eddies beyond, where the clashing particles be- 
come audible ; and the loudness of this murmur 
depends in part upon the force with which the cur- 
rent is propelled. 



EXPLORATION OF THE HEART. 155 

Let the student take a soft-rubber tube, say two 
feet long and one inch in diameter, through which 
water is being driven with considerable power, and 
he will find an example of this sonorous wave, as 
well as of the variation of intensity with the propul- 
sive force ; for, wherever he interrupts the stream by 
squeezing the pipe, he will hear a murmur, with his 
ear upon the tube, and this murmur will be most 
perceptible at the further side of the compression. 
Moreover, it will be loud or soft as the pressure of the 
current is raised or lowered. 

Now this same thing happens when changes occur 
in the valves that agitate the otherwise noiseless flow 
of blood. For instance, a contraction of the mitral 
orifice scatters the stream in the left ventricle ; and 
a like condition at the aortic aperture dissipates the 
current in the ascending portion of the aorta. So, 
too, a reflux at the mitral opening is thrown into audi- 
ble vibration in the left auricle by the imperfectly 
closed valve, which is practically an obstruction ; and 
in a similar manner regurgitation from the aorta is 
attended by a sonorous jet into the left ventricle. 

Just how an anaemic bruit is produced, however, 
is not so clear ; but it is assumed that the aorta and 
pulmonary artery at their commencement do not con- 
tract in proportion to the reduced volume of the 



156 EXPLORATION OF THE CHEST. 

blood, and that tumultuous vibrations are developed 
from the passage of the fluid into these relatively 
dilated cavities. 

Although lesions of the valves that cause stenosis, 
patency, or both at once, usually give rise to mur- 
murs, it does not follow that all murmurs of the heart 
have this significance, nor that some of these aper- 
tures may not be seriously affected without a mani- 
festation of this kind. Nevertheless, the coincidence 
of a bruit and a lesion is sufficiently common to war- 
rant the establishment of such a rule. But in view of 
the fact that it is far easier to detect these noises than 
to determine their purport, the student should never 
fail to scrutinize the whole heart in his endeavor to 
solve the meaning of a murmur. "Wherefore, it is es- 
sential to know what effect a valvular disease may 
have upon the cavities of this organ, for certain modi- 
fications are sure to follow (in a degree conservative), 
which help to substantiate the diagnosis. Thus, with 
stenosis of the aortic orifice, there is hypertrophy of 
the left ventricle ; with a like contraction of the 
mitral aperture, there is a dilated hypertrophy of the 
left auricle, and also in the end of the right side of 
the heart ; with insufficiency of the aortic valves, there 
is dilatation as well as hypertrophy of the left ven- 
tricle ; with the same failure in the competency, of 



EXPLORATION OF THE HEART. 157 

the mitral valve, there are dilatation and hypertrophy, 
first of the left auricle and then of each ventricle ; 
and with both stenosis and insufficiency at the aortic 
opening, the entire heart eventually becomes exces- 
sively enlarged. 

Still, in spite of all that, so long as the hypertro- 
phy keeps pace with the extra requirements of the 
heart, the disease is somewhat in abeyance, and the 
lesions are said to be compensated ; but, when hyper- 
trophy lags behind dilatation, there comes a rupture 
in the established equation — a danger-signal which 
betokens the approaching fatal termination of the 
malady. 

The quality of a murmur can not be said to be an 
index to the gravity of a lesion, since some bruits are 
loud, others soft ; one harsh, and another cooing ; yet 
at the same time a certain amount of information can 
be gained thereby. 

It is evident, from the manner in which a bruit is 
developed, that, if the muscular tone of the heart is 
good, there will be more intensity to the sound than 
when the organ is weak. It is also plain that, where 
regurgitation is extensive, the duration of the murmur 
will be shorter than where the return current meets 
with considerable obstruction in a valve not wholly 
incompetent. Then, too, where a portion of the valve 



158 EXPLORATION OF THE CHEST. 

does its work, a modicum of the sound is often audi- 
ble through the murmur. Furthermore, the examiner 
receives no little aid in diagnosis from the fact that 
the bruit of mitral stenosis is invariably rough and 
grating, that of ansemia always soft and blowing; 
also, that where two cardiac murmurs coexist, with a 
wide diffusion, there is frequently enough unlikeness 
to establish their separate origin. 

Notwithstanding these few points, however, with 
a given murmur, the question presented is not so 
much in regard to its quality as to the integrity of 
the heart-muscles. Is there sufficient hypertrophy to 
compensate for the lesion, or has secondary dilatation 
occurred, and the disease begun its downward course ? 

There are three things to be taken into account 
with respect to a murmur subsequent to its discovery, 
namely, the point of maximum intensity, the rhythm, 
and the area of diffusion ; but attention will be given 
to these further on. 

A valvular bruit takes the place or part of the 
place of a valvular sound, or else precedes it. And 
in the genesis of a murmur there is a silent stage, 
when the valvular sounds are more or less muffled ; 
then a transition stage, when the sounds might be 
called murmurish ; and, finally, a stage wherein the 
bruit is unmistakable. 



EXPLORATION OF THE HEART. 159 

Sometimes a murmur that is inaudible while the 
patient stands is clearly audible when he lies ; and, 
contrariwise, a murmur that can not be heard while the 
patient lies may be easily heard when he stands. Ex- 
ercise not infrequently rouses an otherwise dormant 
murmur. Medication often restores the muscular 
power of the heart, and thereby generates a bruit 
where there was silent leaking. Lastly, in the impact 
of the heart against the lung, the inspiratory murmur 
may be so divided into little whiffs as to resemble an 
endocardial bruit ; but such a source of error can be 
eliminated by causing the patient to hold his breath 
for a moment during the exploration. 

Systolic Murmurs. — Before turning to the physical 
manifestations of heart-disease in their entirety, it will 
be of service to consider the bruits by themselves, and 
also their probable field of action. Reference has 
already been made touching the discovery of a mur- 
mur ; and, inasmuch as disease is more prone to set- 
tle upon the valves of the left than upon those of the 
right side of the heart, we have chiefly to deal with 
bruits having an origin in that part of the organ. 

There are two murmurs possible for each orifice, 
or eight in all, of which four, namely, mitral systolic, 
mitral presystolic, aortic systolic, and aortic diastolic, 
are most likely to ocsur, and with a frequency about 



160 



EXPLORATION OF THE CHEST. 



in the order of their enumeration ; and, the necessary 
changes being made, a like distribution applies to the 




Yalves of the heart (Bonamy and Beau). 1, Bight auriculo-ventricu- 
lar orifice, closed by the tricuspid valve ; 2, fibrinous ring; 3, left 
auriculo-ventricular orifice, closed by the mitral valve ; 4, fibrin- 
ous ring ; 5, aortic orifice and valves ; 6, pulmonic orifice and 
valves ; 7, 8, 9, muscular fibers. 

right side, yet a pulmonary lesion is almost unknown, 
except as a congenital affection, while disease of the 
tricuspid valve is only less rare. 

Every murmur is determined by the time of its 
occurrence, the direction which it takes, and the loca- 
tion of its greatest intensity. Now the blood is driven 
from the left ventricle, during systole, through the 
aortic orifice ; and, meanwhile, all communication with 



EXPLORATION OF THE HEART. 161 

tlie auricle of this side is cut off by a closure of the 
mitral valve. But should the current encounter an 
obstacle at the aortic opening to its onward course, it 
would be thrown into confusion in the aorta, from 
which a murmur would arise and be carried upward. 
Hence this bruit is loudest at the aortic area, sys- 
tolic in rhythm, and extends in the direction of the 
carotids. 

On the other hand, should the mitral valve fail to 
close at this time, the blood would escape into the 
left auricle, as well as run through the proper chan- 
nel, and be set in vibration by the impeding flaps at 
the mitral orifice. Here the bruit generated by this 
disturbance is borne with the reflux into the auricle, 
and thence to the back, and also by conduction 
through the apex to the front. Moreover, it is loud- 
est in front and at the apex, because the heart is 
nearer the anterior than the posterior surface of the 
chest. Therefore this murmur is most intense at the 
mitral area, systolic in rhythm, commonly diffused to 
the left, and often audible near the inferior angle of 
the left scapula. 

In a similar manner, during systole, the blood is 

being propelled by the right ventricle through the 

pulmonary aperture, and, likewise, the tricuspid valve 

is closed or very nearly so. Thus, supposing that an 
s 



162 EXPLORATION OF THE CHEST. 

obstruction were to occur at the pulmonary orifice, 
there would be a systolic murmur, with point of maxi- 
mum intensity in the pulmonary area, and extension 
upward to the left, but not into the carotids. Still, 
practically, this need not occupy our attention. 

So, too, in the event of tricuspid insufficiency, 
part of the blood would flow back into the right au- 
ricle, and give rise to a systolic bruit, best heard in 
the tricuspid area, and spreading upward to the right, 
yet not far. 

An anaemic murmur is always systolic in rhythm, 
loudest at the base of the heart, and often as audible 
in the aortic as the pulmonary area. Furthermore, 
with anaemia pure and simple there should be no car- 
diac hypertrophy. 

ISTow and then a systolic bruit is evolved from a 
disorder in the dynamics of the heart. The writer 
has seen an example of this, wherein the papillary 
muscles seemed to be, as it were, thrown out of 
gear, and the valvular flaps made inadequate by an 
epileptiform seizure. A young man was overcome 
by a spasm while being examined with a stetho- 
scope, in whom a systolic murmur appeared over the 
left ventricle that was not present before the attack, 
and that disappeared in the subsidence of the spasm. 

Not infrequently a systolic sound, closely simu- 



EXPLORATION OF THE HEART. 163 

lating a murmur, is audible in the tricuspid area, 
especially when there is a depression at the lower end 
of the sternum. This is attributed by "Walshe to fric- 
tion of a little white patch often found post mortem 
on the surface of the right ventricle. 

Upon several occasions, more particularly when 
some obstruction already existed in the pulmonary 
circulation, from emphysema, for instance, the writer 
has heard a temporary tricuspid systolic bruit, which 
was brought about by the superadded pressure of 
a held inspiration, and was undoubtedly due to a tran- 
sient dilatation of the right auriculo- ventricular orifice. 

Lastly, when from any cause the cardiac chambers 
become dilated, and the valves are thereby rendered 
insufficient, systolic murmurs may appear, which, 
however, will vanish if mural integrity can be re- 
stored. 

Diastolic Murmurs. — In diastole the aortic and pul- 
monary valves are closed, and the auriculo-ventricular 
valves open, while blood is flowing from the auricles 
to the ventricles. The vermicular contraction, styled 
cardiac systole, which was initiated in the veins and 
taken up by the auricles, has gone through the ven- 
tricles and reached the large arteries, wherein the 
recoil of the current finds a point of support at the 
closed semilunar cusps. 



164 EXPLORATION" OF THE CHEST. 

But, if the function of one or more of these 
cusps in the aortic valve be destroyed, each con- 
traction of the artery will drive a portion of its con- 
tents back into the left ventricle ; and the vibrations 
generated in this return-stream against the disorgan- 
ized valve will cause a bruit that is aortic in origin 
and diastolic in rhythm. 

Now, though this murmur of insufficiency is con- 
veyed along the arteries a varying distance in the 
efflux, its main direction is backward with the reflux ; 
still, not so much in the line of the ventricle as 
down the sternum, owing to the close proximity of 
this bone to the aortic valves, and its superiority 
over the heart as a conducting medium of sound. 
Furthermore, the point of maximum intensity of this 
bruit is oftener at the lower end of the sternum 
than in the second intercostal space. 

Upon the other side, granting that the same 
thing could happen to the pulmonary valves, a dias- 
tolic murmur would be audible in the pulmonary 
area, but with an extension downward only. 

Exceptions. — Although an aortic systolic murmur 
is loudest in the second right intercostal space close 
to the sternum, and a diastolic bruit at the lower 
extremity of this bone, yet, in some instances, these 
murmurs are heard only at mid-sternum, about on a 



EXPLOKATION OF THE HEART. 165 

level with the third costal cartilages, and in others 
they are most intense in the second, and even the 
third intercostal space, close to the left edge of the 
sternum. In consequence of this, upon the exclu- 
sion of aneurism, a bruit within these precincts is 
presumably aortic and not pulmonary, especially if 
the right ventricle is unenlarged. 

Presystolic or Auricular Systolic Murmurs. — The 
relatively passive flow of blood from auricle to ven- 
tricle, during the second cardiac silence, receives a 
sudden impetus, toward the close of this silence, by 
the contraction of the auricle ; and should there be 
an abnormal narrowing of the mitral orifice, the im- 
pediment to the current, in addition to its increase 
of velocity, would throw the stream into sonorous 
jets. 

Thus a murmur becomes audible a little above 
the apex of the heart, and just before the systole of 
the ventricle, that is termed mitral presystolic, but 
which in reality is auricular systolic in rhythm. This 
bruit is conveyed neither to the back nor to the 
left, nor yet very far in any direction. 

A like affection of the tricuspid aperture would 
result in a murmur of the same rhythm, and be 
confined to that area; but, clinically, such a disease 
is rarely met with. 



166 EXPLORATION OF THE CHEST. 

Xow and then, as first explained by Flint, an 
auricular systolic murmur is audible in the mitral 
area that is due, not to stenosis of this orifice, but 
rather to the vibrations set up by the valvular 
flaps, which have been floated into contact by the 
blood returned from an aortic regurgitation, and 
which are suddenly driven apart by the auriculo- 
ventricular current. The writer has seen two or 
three cases that apparently were of this descrip- 
tion. 

Pericardial Murmurs.— The bruits of the peri- 
cardium, more properly termed friction, are devel- 
oped between the visceral and parietal layers of this 
membranous sac, during either systole, diastole, or 
else both movements of the heart, but with the 
sounds of which they are not continuously synchro- 
nous. This friction, from a roughening of the peri- 
cardium, is often double, always superficial, and fre- 
quently transient. Moreover, though the rubbing is 
seldom heard over a wide area, it extends at times 
quite far, but equally in all directions, rather than 
chiefly, as with many endocardial murmurs, in the 
course of the blood- stream ; and it is loudest when 
the body is bent forward, whereas valvular bruits 
are not particularly influenced by this posture. 

A pericardial is distinguished from a pleuritic 



EXPLORATION OF THE HEART. 167 

friction mainly by the time and locality of its occur- 
rence. Grating in the pericardium obviously is 
limited to the precordial region, and is regulated 
by the action of the heart. That of the pleura is 
most prone to take place in the infra -axillary regions, 
where pulmonary mobility is extensive ; and, further, 
it is dependent upon the respiratory movements. 

Associated Murmurs. — The valvular bruits may be 
variously combined : thus, an aortic systolic with an 
aortic diastolic ; mitral presystolic with mitral sys- 
tolic ; mitral presystolic with tricuspid systolic ; aor- 
tic with mitral systolic: and, also, two murmurs at 
the aortic may be united with two at the mitral 
area. 

Venous Sliirnmrs. — The bruits produced in the 
veins of practical importance are those accompany- 
ing ansemia. Such murmurs are possible without 
this affection, but the affection seldom occurs with- 
out these murmurs. 

In quality they are blowing, cooing, and some- 
times musical ; and, from the not infrequent resem- 
blance of the noise to that of a humming-top, it 
has been denominated venous hum. 

TThile heard elsewhere in the veins, the sound 
is usually most distinct at the lower third of the 
external jugular veins, and in the right than the 



168 EXPLORATION OF THE CHEST. 

left side. It is always continuous in rhythm, but 
the intensity is often remittent, because of the peri- 
odical acceleration of the stream by the action of 
the heart. The direction is downward and inward 
along the subclavian and right innominate veins, so 
that it is now and then audible through the aortic 
area, and can be separated, with a little care, from 
the aortic sounds as well as from the respiratory 
murmur. 

"Where there is a question as to whether or not 
a given bruit is venous or arterial, pressure upon 
the vein above the stethoscope will stop the down- 
ward current and silence the venous hum ; but, un- 
less more force is employed than is required for 
this purpose, it will have no effect upon a murmur 
in the artery. 

Now, the valves of the veins are encircled by 
little fibrous rings, which cause more or less con- 
traction, at these points, in the caliber of the ves- 
sels. May it not be an unusual narrowing of this 
kind in the channel that throws the venous blood 
into vibrations beyond, and thus accounts for the 
bruits which are said to be heard where anaemia 
does not exist? 

There is a valve in the external jugular vein an 
inch and a half above the inner end of the clavicle ; 



EXPLORATION" OF THE HEART. 169 

moreover, in this vicinity, the vein passes between 
the layers of an aponeurosis, to which it is attached, 
and by which it is held apart. Thus the vein, 
always less elastic than an artery, is unable to accom- 
modate its capacity, owing to the adhesions, to the 
diminished bulk of the ansemic blood; hence the 
hypothesis that the stream, meeting with an obstruc- 
tion at the orifice of the valve, is thrown into sono- 
rous vibrations in the relatively dilated cavity at the 
further side ; and, inasmuch as the venous current 
is increased in its rapidity by its near approach to 
the heart, as well as by the force of gravity, and also, 
to some extent, by the suction power exerted through 
inspiration, this is just w r here the bruit should be 
loudest. 

A similar disturbance can be brought about, in 
seme instances, by gentle pressure with the stetho- 
scope upon the vein. So too, an enlargement of 
the thyroid gland may have this same effect. 



DIAGNOSIS BY PHYSICAL SIGNS OF DIS- 
EASES OF THE HEART AND OF THO- 
RACIC ANEURISM. 

ENDOCARDITIS. 

An acute inflammation of the endocardium is 
more prone to affect the left than the right side of 
the heart, and to settle upon the mitral than the 
aortic valve. It occurs most frequently with rheu- 
matic fever, and reveals itself by a soft, blowing mur- 
mur that, as a rule, is located in the mitral area, 
with an extension to the left, and which is systolic in 
rhythm. 

Still, should a systolic bruit ariss at the base of 
the heart during the progress of this disease, though 
possibly haemic, it might come from an affection of 
the aortic valve ; and, furthermore, were a diastolic 
bruit to appear, it would be conclusive evidence that 
one or more cusps had been destroyed. 

Whenever there is a sudden rise of the tempera- 
ture in the course of rheumatism, the examiner must 



ENDOCARDITIS. 171 

not fail to include the heart in his search for the 
source of this elevation. 

The possibility of an old valvular trouble with a 
new rheumatic seizure should be entertained, yet it 
usually can be dismissed if there prove to be no 
cardiac hypertrophy. 

On the other hand, the supervention of an acute 
upon a chronic valvulitis is rather difficult to deter- 
mine by physical exploration. 

Acute ulcerative endocarditis happens in connec- 
tion with blood-poisoning, and is liable to be masked 
by inflammatory affections of the pericardium, lungs, 
or pleura, due to the same cause. Hence the appear- 
ance of a systolic or a diastolic blowing murmur in 
a septic disease of low type would warrant the diag- 
nosis of an ulcerative form of valvulitis. 

It is claimed by Balfour that bruits heard during 
acute rheumatism are often the result of dilatation 
of the cavities from a relaxation in the heart-muscles, 
with a consequent failure in the adjustment of the 
valvular flaps, and that such bruits disappear w^hen 
convalescence is established. 

But this malady is not the sole cause of valvulitis, 
for the inflammation may be chronic from the com- 
mencement, obscure in its origin, and eventually lead 
to results quite as disastrous ; and then, too, a founda- 



172 EXPLORATION OF THE CHEST. 

tion may be laid in acute rheumatism that at first 
only modifies the valvular sounds, but which later 
reaches unmistakable proportions. 

The chief interest in endocarditis centers upon 
the bearing it may have upon the future history of 
the heart. Now, to non-progressive and to slowly 
advancing lesions, this organ accommodates itself just 
as the body does to moderate impairments of function 
elsewhere, and the patient's existence is only slightly 
if at all imperiled or even incommoded ; whereas, 
with rapidly advancing lesions, on the contrary, there 
very soon comes a disturbance of the balance that 
nature endeavors to maintain, wherein compensatory 
hypertrophy gives way both to dilatation and to mural 
decay. 

It will be seen, therefore, in dealing with chronic 
heart-disease, that it is of considerable consequence 
for the examiner to recognize the difference between 
static and progressive lesions ; and many times this 
may be accomplished by a careful inquiry into the 
history and symptoms, and by a scrutiny, withal, of 
the cardiac cavities. 




THORACIC CAVITY.— LUNGS DRAWN APART. FRONT VIEW 
(HIRSCHFELD). 

1,1, pericardium ; 2, 2, subclavian arteries ; 3, trunk of the right in- 
nominate vein ; 4, trunk of the left innominate vein ; 5, superior 
vena cava ; 6, right phrenic nerve ; 7, left phrenic nerve ; 8, 8, 
diaphragm ; 9, 9, portions of the mediastinal pleura. 



PERICARDITIS. 173 

PERICARDITIS. 

An inflammatory affection of the pericardium is 
rarely idiopathic, but it is freely disposed to compli- 
cate rheumatism, pleurisy, disease of the kidneys, and 
kindred diseases. Moreover, it is often not apparent 
save by physical examination, and this is especially 
the case in chronic nephritis. Of these maladies, 
pericarditis is most commonly associated with rheu- 
matic fever. 

The first positive evidence that the pericardium 
is inflamed is gained by auscultation. A friction is 
heard over the heart, that may be a single rub or a 
to-and-fro grazing sound, which conveys the impres- 
sion of being quite superficial. This sound may be 
loud or soft, and circumscribed or far-reaching ; but 
it differs from most endocardial bruits in being dif- 
fused equally in all directions, rather than mainly 
in the course of the blood-stream. Furthermore, 
though it occurs oftener between the heart-sounds 
than with them, yet it may be so loud as to practi- 
cally obscure them. 

Unlike valvular disease, pericarditis has no effect 
upon the pulmonary second sound. And, finally, 
friction can be intensified by pressing the stethoscope 
against the precordial region, by causing the patient 



m 



EXPLORATION" OF THE CHEST. 



to lean forward, and by his taking a deep breath; 
whereas, these expedients have little if any influence 
upon endocardial murmurs. 

Fever is present, but seldom ranges beyond 
102° F. 

If, by chance, rubbing should take place between 
the pericardium and an inflamed pleura, and continue 




Diagram showing fluid in the pericardial sac. 

even when breathing for a moment is stopped, as it 
now and then will do, the diagnosis of pericarditis 
must remain unsettled until the coming of an intra- 
pericardial effusion, which, however, is usually not 
long delayed. 

Now, upon the advent of fluid, the apex -beat 



PERICARDITIS. 175 

gets hidden, while pulsation is transferred to another 
part of the ventricle, and soon this, too, is lost in the 
increasing accumulation. If the sac fills full, there 
may be more or less bulging over the heart, and the 
intercostal spaces may become widened and immova- 
ble. 

Upon percussion there is flatness from below up- 
ward in the parasternal line and across the prsecor- 
dial region, so that a pyramid is embraced within its 
borders, whose apex may reach to the second rib, 
and base extend as far as or farther than the nipple- 
lines. 

Upon auscultation, the friction is confined to the 
base of the heart or has wholly disappeared, while 
over the apex the sounds of the heart are either weak 
or absent, and around the organ in the area of flat- 
ness the respiratory murmur is suppressed. 

"With the retreat of the fluid, flatness recedes, 
friction comes back to remain a varying period, and 
then fades away. At the same time the respiratory 
murmur returns to the portion of the lung that was 
compressed by the effusion, the apex-beat regains its 
position, and the sounds of the heart are gradually 
restored to their normal vigor. 

"Where adhesions follow in the wake of an effu- 
sion, there is supposed to be a sinking in of two or 



176 EXPLORATION OF THE CHEST. 

three adjacent intercostal spaces over the ventricle, 
with its contractions ; but there is scanty proof of 
the correctness of this supposition, and, accordingly, 
there is no absolute certainty in the diagnosis of such 
a condition. 

HYDROPERICARDIUM. 

A passive effusion of the pericardial sac, of course, 
will not be ushered in by friction nor attended by 
fever, but it is identical, in its physical manifestations 
of fluid, with pericarditis. Hence, the student must 
employ the tests already given for the stage of effu- 
sion, and carefully consider the history and symp- 
toms, remembering that hydropericardium is very 
likely to be associated with dropsy in the body else- 
where. 

CARDIAC HYPERTROPHY. 

The general term hypertrophy, as applied to the 
heart, includes two special forms, namely, an over- 
growth of the muscles without dilatation of the cavi- 
ties, which is simple hypertrophy; and a dilatation 
of the cavities, with an overgrowth of their walls, 
which is eccentric hypertrophy — and of these two 
varieties, the latter is the more common. 

Upon inspection, in simple hypertrophy of the 



CARDIAC HYPERTROPHY. 



177 



heart, there is seen a heaving, regular impulse, and 
the apex is found below the fifth intercostal space, 
and beyond the left nipple-line. 

In eccentric hypertrophy, the apex is carried 
downward, but a little further to the left than in 
simple hypertrophy, and, moreover, the impact is 
somewhat less forcible ; and, if the enlargement be 




Diagram, dotted line to the left showing area of enlargement of left, 
dotted line to the right area of enlargement of the right, side of 
the heart. 



178 EXPLORATION OF THE CHEST. 

confined to the right side, pulsation is most noticeable 
at the epigastrium, while the apex is pushed to the 
left. 

With children, owing to the flexibility of the 
parietes, there is considerable bulging over the heart 
when it is enlarged. 

By palpation, the force of the organ's stroke 
against the chest-wall, and the displacement of the 
apex, can be better appreciated than by inspection. 

Upon percussion, the area of cardiac flatness and 
deep-seated dullness is extended in the direction of 
the augmentation of the heart. The dullness, which 
in health does not exceed the left nipple-line, goes 
beyond this limit in company with the left ventricle, 
and the flatness follows the receding lnng in the same 
direction ; and there will be dullness at the right 
of the sternum, if this side of the heart is enlarged, 
where it is otherwise not demonstrable. 

In very thin persons an increase in the size of the 
left auricle may cause pulsation near the left edge 
of the sternum in the second or third intercostal 
space, and now and then, under these circumstances, 
dullness is carried up the parasternal line above the 
third rib. 

Upon auscultation, in simple hypertrophy there 
is a dull, prolonged, thud-like first sound over the 



CARDIAC DILATATION". 179 

apex, owing to a predominance of the muscular ele- 
ment in the sound, and often an accentuation of the 
second sound at the base, because of an increase in 
the blood-pressure. 

"With eccentric hypertrophy, however, the first 
sound is clear and loud, and the second less in- 
tense than in the former variety of enlargement. 

"When this increase of size is restricted to the 
left side of the heart, the mitral is plainer than 
the tricuspid, and the aortic than the pulmonary 
sound ; and, likewise, when the augmentation is 
confined to the right side, the intensity is trans- 
ferred to the tricuspid and pulmonary valves. 

CARDIAC DILATATION. 

It is commonly understood, by dilatation of the 
heart, that the chambers are enlarged, while, at the 
same time, their walls are reduced in thickness. 
More properly speaking, this is passive and eccen- 
tric hypertrophy is active dilatation. 

There is no visible cardiac impulse with the affec- 
tion, except in very thin persons, and even then it is 
indistinct, wide-spread, and wavy, instead of well- 
defined, concentrated, and steady, as in hypertrophy. 
This pulsation extends below but more especially 



180 EXPLORATION OF THE CHEST. 

beyond the normal position, unless the enlargement 
be confined to the right side of the heart, when 
the impulse is mainly in the epigastric region. 

If appreciable to the hand, the impact is weak 
and irregular, and in marked contrast with the for- 
cible stroke of hypertrophy. 

Upon percussion, the organ is found much in- 
creased in size, and particularly in its lateral dimen- 
sions. 

Upon auscultation, there is revealed a clear, sharp, 
valvular first sound, because of the diminished mus- 
cular element to this sound, or else a very feeble 
one, owing to the impending asystolia. Moreover, 
there will frequently be a faint mitral systolic mur- 
mur, in lieu of the sound, from the resulting pa- 
tency of the auriculo- ventricular valve. 

But, then, it must be remembered that the im- 
pulse of the heart may be weak from general de- 
bility, and, on the other hand, strong simply from 
excitement; and, furthermore, displaced by extrinsic 
causes : hence, these possibilities should be carefully 
weighed before concluding that there is either hy- 
pertrophy or dilatation. 



FATTY DEGENERATION OF THE HEART. 181 

FATTY DEGENERATION OF THE HEART. 

The importance of detecting a fatty metamor- 
phosis of the heart is always great, but at no time 
greater than when the administration of an anaes- 
thetic becomes needful ; for, though a stationary 
valvular lesion, or even a slowly progressive one 
that is well compensated, does not of itself invari- 
ably preclude the use of these agents, yet fatty de- 
generation, on the other hand, uniformly renders 
their employment extremely hazardous, at least for 
surgical purposes. 

Now, while this fatty condition of the heart is 
not impossible in early life, it is much more liable 
to occur in persons well advanced in years. Thus, 
a patient past fifty, more commonly a man, with 
a pale, pasty skin, bedewed with clammy perspira- 
tion, who suffers from palpitation of the heart and 
dyspnoea, and that peculiar ascending and descending 
rhythm of breathing termed Cheyne-Stokes respira- 
tion, would furnish excellent reasons for a suspicion 
of fatty decay, and especially if he also had more 
or less angina pectoris, with now and then a pseudo- 
apoplectic seizure ; and add to this atheroma of the 
arteries and a true arcus senilis, and the suspicions 
would pass into the realms of probability. 



182 EXPLORATION" OF THE CHEST. 

But the physical signs, aside from those of the 
organic lesions with which this disease may be as- 
sociated, are somewhat meager. The impulse of 
the heart is either invisible, or very faintly dis- 
tinguishable. There may be little if any enlarge- 
ment, or the extreme expansion of dilatation. Upon 
auscultation the sounds of the heart are feeble, 
and the .first sound at the apex is but a short flap 
of the leaves, or else it is lost. 

Lastly, the action of the heart may be regular 
and abnormally slow, or rapid and very irregular, 
and withal so weak that many of the contractions 
fail to send an appreciable wave to the wrists. 

Still, after all, it too often comes to pass that 
death takes place where neither signs nor symptoms 
had given warning of the mural decay found in 
the end to have been the cause of sudden disso- 
lution. 

AORTIC STENOSIS. 

Since an obstruction at the aortic orifice puts 
an additional tax upon the left ventricle, and, at 
the same time, throws the blood into sonorous 
vibrations along the aorta, the muscles of this ven- 
tricle become hypertrophied, and a murmur is gen- 
erated with every cardiac systole. 



AORTIC STENOSIS. 183 

Consequently, the apex is seen, upon inspection, 
striking the chest below the fifth intercostal space, 
and somewhat beyond the left nipple-line ; and, 
moreover, the impulse may be so strong as to cause 
a slight upheaving of the prsecordia with each ven- 
tricular contraction. 

By palpation, the force of this impact is appre- 
ciated, and also, in many instances, a systolic thrill 
over the base of the heart can be felt. 

By percussion there is revealed an extension of 
the flatness and dullness of the heart to the left 
and downward. 

Upon auscultation there is a bruit with greatest 
intensity close to the sternum in the second right 
intercostal space, with rhythm systolic, and with direc- 
tion upward. It is usually harsh in quality, and 
sometimes both loud and harsh. The aortic second 
sound may be obliterated by this lesion. Now and 
then these murmurs are loudest at mid-sternum, on 
a level with the third costal cartilages, or to the 
left of this bone, in the second and possibly the 
third intercostal space ; and they may be conveyed 
by conduction along the anterior surface of the 
chest to the left. Still, the only lesion that might, 
under these circumstances, be mistaken for aortic 
stenosis, is a contraction of the pulmonary orifice ; 



181 EXPLORATION OF THE CHEST. 

bat this is extremely rare, and would be associated 
with hypertrophy of the right and not the left ven- 
tricle. 

Neither mitral nor tricuspid systolic murmurs 
are carried very far upward, nor, as a role, are 
they harsh in quality. A dynamic bruit may be 
excluded if the heart is tranquil, and the absence 
of anaemia would preclude a hgemic murmur ; and, 
furthermore, a dynamic murmur, a hsemic bruit, or 
a simple roughening of the aortic orifice would not 
be attended by hypertrophy of the left ventricle. 

The physical signs, then, of aortic stenosis are 
those of hypertrophy of the left ventricle, and of 
an aortic systolic murmur ; and, though it is not im- 
possible for this lesion to exist without a murmur, 
the obstruction could not be very extensive without 
producing an effect upon the left ventricle. 



AORTIC INSUFFICIENCY. 

From inadequacy of the aortic valve, blood is 
returned to the left ventricle, and eddies are formed 
in the reflux, so that the left ventricle becomes en- 
larged, and also diastolic bruits are produced. 

Therefore, by inspection, the apex is located well 
to the left of, and below its normal position. 



AORTIC INSUFFICIENCY. 185 

By palpation the impulse, though moderately 
strong, is less concentrated than in simple hyper- 
trophy. 

Upon percussion, the dullness of the heart is 
defined beyond the left nipple-line, and below the 
fifth intercostal space, and the flatness increases in 
proportion to the dullness. 

Upon auscultation, there is a diastolic murmur, 
that may be loud or soft, and harsh or smooth, 
and which has its point of maximum intensity in 
the second right intercostal space near the sternum. 
This bruit extends up the arteries, and also down 
with the reflux, and it may be loudest at the lower 
end of the sternum. But sometimes it can be heard 
only at mid-sternum, on a level with the third costal 
cartilages, or at the left edge of this bone, a little 
lower. 

If the aortic second sound is not wholly obscured 
by the murmur, it is an evidence that the valve is 
not entirely defective ; whereas, if there is no val- 
vular sound, and the murmur is soft and abrupt, 
there is probably free regurgitation ; and the less 
opposition to the backward flow of the blood, the 
sooner the circulation of the heart, and thereby its 
nutrition, will suffer. 

A diastolic bruit is the most constant of bruits, 



1S6 EXPLORATION OF THE CHEST. 

and it is not likely to exist without regurgitation, 
nor, on the other hand, is regurgitation likely to 
occur without a murmur, but the insufficiency may 
be due to a dilatation of the aorta, and not neces- 
sarily to a lesion of the valve. 

It is not often that the lines are clearly drawn 
between stenosis and patency of the aortic valve ; 
and, where the lesions coexist, there are commonly 
two murmurs, one with systole and one with dias- 
tole. These are to-and-fro, oftentimes loud, harsh 
bruits, and widely diffused. Moreover, the heart is 
extensively enlarged by this combination. 

The attempt has been made to formulate a method 
for deciding whether stenosis or patency predomi- 
nates in a given lesion, by the relative quality, and 
also by the direction of the bruits ; and, inasmuch 
as the prognosis is best w T here there is most ob- 
struction, such a decision is desirable. But these 
distinctions are more or less fallacious, while, on 
the other hand, considerable reliance can be placed 
upon the nature of the radial pulse ; for in extensive 
regurgitation this pulse is quite characteristic. A 
large volume of blood is thrown into the arteries and 
with great force by the hypertrophied left ventricle, 
and the wave strikes the wrist in a full and abrupt 
manner, but it falls away just as abruptly, owing to 



MITRAL STEXOSIS. 187 

the reflux into the left ventricle. This is known as 
the water-hammer, or as Corrigan's pulse, and it is 
made still more obvious by elevating the patient's 
arm. Xow it follows that the more stenosis there is 
the more sustained will be the column of blood, and 
the less sudden the recoil from the wrist, and there- 
fore the smaller the regurgitation. 

To recapitulate, the physical signs of aortic insuffi- 
ciency are those of enlargement of the left ventricle, 
and of an aortic diastolic murmur ; while there are 
both systolic and diastolic murmurs, as well as an en- 
largement of the left ventricle, in stenosis with in- 
sufficiency. 

MITRAL STEXOSIS. 

As a result of obstruction at the mitral aperture, 
vibrations are set up in the blood-stream as it is pro- 
pelled into the left ventricle, and the left auricle and 
right ventricle become enlarged, while the left ven- 
tricle, in uncomplicated stenosis, is not only not en- 
larged but frequently decreased in size. 

Upon inspection, pulsation is noticeable in the 
epigastrium, and, if the patient is very thin, also over 
the left auricle, in the vicinity of the sternum, at the 
third left intercostal space. 

By palpation the apex is located about in its nor- 



18S EXPLORATION OF THE CHEST, 

mal position ; and often over the left ventricle a thrill 
is communicated to the hand during the last portion 
of the second silence of the heart, that runs up to the 
apex-beat. The presence of this thrill, even in the 
absence of a bruit, strongly points to stenosis. 

Upon auscultation, a harsh, grating, unusually 
loud murmur is heard just above the apex, where also 
it is most intense ; yet, however loud, it has a very 
limited area of diffusion, and is rarely if ever con- 
veyed to the back. This bruit is auricular systolic, 
or, with respect to the ventricle, presystolic in rhythm ; 
that is to say, it occurs during the latter part of the 
second silence of the heart, while the auricle is con- 
tracting, or just before the systole of the left ventri- 
cle. The pulmonary second sound is intensified, and 
the degree of accentuation is thought to indicate the 
amount of the obstruction. On the other hand, there 
is so little stress upon the aortic second sound that it 
is almost inaudible at the mitral area. There may be 
also a reduplication of the cardiac second sound from 
a lack of simultaneous action of the two sides of the 
organ. 

A mitral presystolic murmur, as a rule, is not 
difficult to recognize. It is lost as the stethoscope is 
moved far in any direction from the apex, and while 
listening, if the examiner will place a finger upon the 



MITRAL STENOSIS. 189 

carotid artery, which beats in synchronism with the 
ventricle, to make sure of ventricular systole, he will 
hear a murmur coming up to the first sound aud to 
apical impact that is suddenly cut off, as it were, in 
the midst of its fullness, by the first sound. There is 
some danger, however, of mistaking the first for the 
second sound, under these circumstances, owing to 
the altered quality of the former, and because the 
second sound may fail to reach the mitral area. But 
a knowledge of this possible source of error should 
enable the examiner to avoid being misled thereby. 

It is seen, therefore, that the diagnosis of mitral 
stenosis rests upon the presence of a mitral presystolic 
bruit, a presystolic thrill, and upon the evidences of 
enlargement of the left auricle and right ventricle, 
but not of the left ventricle. 

Mitral Stenosis with Insufficiency. — Stenosis with, 
at the same time, patency of the mitral orifice is at- 
tended by two murmurs, which in some instances 
remain separate and in others become continuous. 
The first murmur is presystolic and the second sys- 
tolic in rhythm ; and a very good way to distinguish 
one murmur from the other is by moving the stetho- 
scope to the left, beyond the limit of presystolic dif- 
fusion, where the mitral systolic murmur still con- 
tinues audible. With a double lesion, the left ven- 



190 EXPLORATION OF THE CHEST. 

tricle is enlarged in proportion to the excess of pa- 
tency over stenosis of the valve, and of hypertrophy 
over dilatation of the left auricle. 

This is the commonest affection of the mitral 
valve, yet two murmurs are by no means the absolute 
rule. If the student will bear in mind the great mus- 
cular power of the left ventricle, compared with that 
of the left auricle, he will have no difficulty in under- 
standing, especially if this auricle has passed into sec- 
ondary dilatation, why a mitral systolic may be the 
only murmur, even when stenosis is the chief lesion ; 
for the strong ventricle will drive the blood back 
through the patent orifice, and thus develop a systolic 
murmur, after the weak auricle has failed to throw 
the direct current into audible vibrations. These 
comprise many of the mitral systolic murmurs that 
are transmitted neither to the back nor far if at all to 
the left. 

Now and then instances arise wherein two or 
three ineffectual attempts at ventricular systole occur 
before a well-defined murmur or a radial pulsation is 
perceptible — not in this case from an asystolia or 
weakness of the ventricle, but when there is reason 
to believe its contractility good, from (in the writer's 
opinion) a delay in the filling of that chamber, pos- 
sibly in part through feebleness of the auricle, yet 



MITRAL INSUFFICIENCY. 191 

mainly from the obstruction offered at the mitral 
valve to the anriculo-ventricular current. 

Finally, it should be known that these two mur- 
murs are inconstant and interchangeable as well, 
but, once established, the lesion is always present ; 
from which it may be inferred that a difference of 
opinion between competent examiners, respecting the 
diagnosis on separate occasions, ought to be adjusted 
upon a basis of this understanding. 



MITRAL INSUFFICIENCY. 

If, during the systole of the left ventricle, blood is 
returned to the left auricle, a murmur will arise with 
each contraction, and the left auricle will become en- 
larged, then the right ventricle, and also to some de- 
gree the left ventricle. 

Upon inspection, there is epigastric pulsation, and 
the apex is depressed and carried to the left. 

By palpation, the impulse is found to be strong or 
weak in proportion to the hypertrophy or dilatation. 
Should the patient be very thin, the action of the en- 
larged left auricle would be felt ; and, too, by palpa- 
tion, a systolic thrill is sometimes appreciable over 
the left ventricle. 

Upon percussion, an increase in the area of flat- 



192 EXPLORATION OF THE CHEST. 

ness and dullness may be developed vertically as well 
as horizontally ; yet all percussion-signs of the heart 
depend somewhat upon thinness of the chest-wall for 
their utility. 

By auscultation there is revealed a soft, blowing, 
sometimes musical bruit, whose greatest intensity is 
over the apex or mitral area, and that is systolic in 
rhythm. Taking the place, or part of the place, of 
the first sound at the apex, this murmur is diffused to 
the left, and also transmitted through to the back, 
where it is audible near the lower angle of the left 
scapula, and at times along the spine from the fourth 
to the eighth vertebra, and even to the right of the 
spinal column. But when insufficiency is complicated 
by stenosis, so that regurgitation is slight, or when 
ventricular systole is weak, the area of diffusion is 
circumscribed, and the murmur is inaudible at the 
back. Moreover, there is often considerable accentu- 
ation of the pulmonary second sound. The less the 
murmur encroaches upon the click of the mitral valve, 
the smaller the amount of the reflux. 

A mitral is distinguished from a tricuspid systolic 
bruit by its point of maximum intensity and the di- 
rection which it takes. The former fades toward the 
right, whereas a tricuspid bruit grows plainer and is 
loudest at the lower end of the sternum. 



TRICUSPID INSUFFICIENCY. 193 

It is possible for an emphysematous lung to ob- 
scure both mitral sounds and bruits, or, by depressing 
the apex, to carry them in the direction of the tricus- 
pid region. 

From the foregoing it is evident that a mitral 
systolic murmur, associated with enlargement of the 
left auricule and of each ventricle, is a proof of more 
or less reflux at the mitral orifice ; and the more com- 
pletely the bruit invades the first sound at the mitral 
valve, and the greater the intensification of the pul- 
monary second sound, the more extensive the regur- 
gitation. 

TRICUSPID INSUFFICIENCY. 

A reflux at the tricuspid orifice enlarges the right 
auricle, and if the patency of the valve, caused by 
either valvulitis or simple dilatation, be due primarily 
to mitral disease, which is commonly the case, there 
will be an enlargement not only of the right auricle, 
but also of the right ventricle, left auricle, and, with 
mitral insufficiency, of the whole heart. On the other 
hand, where the incompetency is owing to a chronic 
pulmonary disease only, as it sometimes is, the in- 
crease of size will be confined to the right side of 
the organ. 

Upon inspection, there is seen an epigastric and 



19± EXPLOKATION OF THE CHEST. 

perhaps an auricular impulse ; while, if regurgitation 
be extensive, there is also a systolic pulsation in the 
right and, possibly, the left jugular vein. 

On palpation, unless there be hypertrophy of the 
left ventricle, the apex-beat is either absent or at 
least not strong. 

To decide between a transmitted impulse from 
the carotid artery and an original pulsation in the 
jugular vein, the examiner has but to stop the down- 
ward current of the vein by compressing this vessel 
at the middle of the neck ; for a simulated venous 
pulse ceases below the pressure, whereas the back- 
ward flow from the heart through the vein will con- 
tinue. 

By percussion there is developed an increase in 
the dullness over the heart, especially to the right 
of the sternum. 

Upon auscultation, a soft, blowing, systolic mur- 
mur is revealed, that takes the place, or part of the 
place, of the first sound in the tricuspid area. This 
murmur is superficial, not widely diffused, and is sel- 
dom audible above the third rib. 

Although a mitral systolic bruit may reach the 
tricuspid area, and thereby convey an erroneous im- 
pression that the right side of the heart is affected, 
yet, in such an event, the fact must be recalled that 




THORACIC CAVITY.— LUNG DRAWN FORWARD. BRONCHI AND PUL- 
MONARY VESSELS EXPOSED. VIEW FROM THE LEFT SIDE 
(HIRSCHFELD). 

1, trachea ; 2, oesophagus ; 3, arch of the aorta ; 4, left pneumogastric nerve ; 
5, thoracic aorta ; 6, intercostal vessels and nerves. 



THORACIC ANEURISM. 195 

a tricuspid is scarcely ever propagated, like a mitral 
murmur, to the left beyond the apex ; and, too 
under these circumstances, that the unaltered sounds 
of the tricuspid valve would be audible. And were 
an aortic systolic murmur to pass down the sternum, 
which as a rule it does not, it would be heard also 
in the carotids, where the tricuspid bruits never 
extend. 

It follows, accordingly, that a tricuspid systolic 
murmur, with enlargement of the right side of the 
heart, indicates a reflux from the right ventricle to 
the auricle of the same side. And venous pulsation 
in the neck, together with cyanosis and oedema, would 
evince a very considerable regurgitation. 

THORACIC ANEURISM. 

It has been shown by careful investigation that 
the frequency of thoracic aneurism diminishes with 
the increased distance of the artery from the heart. 
Hence, of the three subdivisions of the aorta, the 
ascending is most commonly the seat of aneurism, 
the transverse next, while the descending portion is 
least commonly affected. 

In the iirst instance, the tumor tends to the right 
of the sternum, in the vicinity of the second or third 



196 EXPLORATION OF THE CHEST. 

costal cartilage, and it may eventually pass beyond 
the right nipple ; in the second, it frequently does 




Diagram showing an aneurism of the ascending aorta. 

not reach the surface of the chest, or at least pro- 
ject therefrom ; still it may, now and then, be seen 
at the left of the sternum, near the second costal car- 
tilage ; in the third instance, the aneurism is usually 
deep-seated, and from its location invades the spinal 
column, rather than the anterior part of the thorax. 
Upon inspection, if the tumor has involved the 
front wall of the chest, there will be bulging over 
this area, and more or less impairment in the re- 
spiratory play of the implicated region. Moreover, 
a pulsation is visible in this protuberance that keeps 



THORACIC ANEURISM. 197 

time with the beating of the heart ; and, even be- 
fore there is a perceptible swelling, this impulse 
may be seen by looking across the chest, instead 
of by taking a front view* So, too, some of the 
results of pressure are found on inspection, such as 
fullness of the veins and oedema in the neck and up- 
per extremities, caused by obstruction of the descend- 
ing vena cava. 

By palpation, a thrill is sometimes felt with the 
hand over the aneurism, and, when the tumor can 
be grasped, also an expansive impulse that is peculiar 
to this malady. 

On mensuration, an increase in the interval be- 
tween the median line and the nipple of the affected 
side is shown. 

By percussion, let it be the gentlest of strokes, 
flatness is disclosed over that part of the tumor which 
impinges upon the chest-wall, and dullness, or pos- 
sibly tympanitic resonance, over the compressed 
lung. 

Through auscultation a murmur may be revealed 
that is usually single and systolic in rhythm, and 
which is not infrequently louder than most cardiac 
bruits; but often there will be nothing more than 
an impulsive throb and the intensified heart-sounds 
over the aneurism ; and, should there happen to be 



198 EXPLORATION OF THE CHEST. 

pressure upon a large bronchus, vesicular breathing 
would be suppressed, or at least enfeebled in the 
region cut off, and sonorous rales would become 
audible. Lastly, vocal resonance may be absent in 
this vicinity as well as over the tumor.. 

Since an aneurism seated in the transverse por- 
tion of the aorta is not always inclined toward the 
surface, fewer distinctive signs are apt to arise than 
when the first division of the vessel is occupied ; 
but, on the other hand, the pressure symptoms are 
more numerous. For example, there is dyspnoea 
from compression of the trachea, the left bronchus, 
or else of the pneumogastric nerves. In the latter 
case the difficulty is intermittent, and there is a loud, 
dry, metallic cough ; in the former conditions it is 
continuous, and the cough is attended by blood-tinged 
sputa. With obstruction of the air-tubes there will 
be sonorous respiration ; pressure upon the pneumo- 
gastric nerve produces paralysis of the vocal cord 
of the affected side. This loss of function in the 
cord is clearly shown by laryngoscopic examination. 
Where the oesophagus is implicated, there is re- 
curring dysphagia. Pressure upon an artery causes 
delay or, possibly, disappearance of pulsation in the 
distal extremity of the vessel ; pressure upon the cer- 
vical sympathetic nerves is manifested by a con- 



THORACIC ANEURISM. 199 

traction of the pupil in the eye of the side in- 
volved. An inequality of the pupils, however, is 
not necessarily a sign of disease, for it is some- 
times found in healthy persons. Finally, pressure 
upon bone, cartilage, and nerve gives pain. 

Wherefore, it may be concluded that a tumor 
of the anterior thoracic parietes, pulsating syn- 
chronously with the heart, outside its precincts, in 
coequal or greater force, that is expansile withal, 
and which is attended by some of the evidences 
of pressure, is undoubtedly an aneurism. 



INDEX. 



Abscess of lung, 105. 

Absence of vesicular breathing, 63. 

Absorption (pleurisy), 118. 

Accentuation of heart-sounds, 154. 

Acoustics, 44. 

Adhesion (pleural), 119. 

(pericardial), 175. 
Adventitious signs, 70. 
iEgophony, 79. 
Alterations in symmetry of chest, 

21. 
Amphoric breathing, 67. 

resonance, 48. 

voice, 79. 
Anaemia, 20. 
Anaemic bruit, rhythm of, 162. 

theory of, 155. 
Anaesthesia in heart-disease, 181. 
Aneurism (thoracic), 195. 
Aorta, thoracic, 142. 
Aortic insufficiency, 184. 

stenosis, 182. 
Arteria innominata, 142. 
Artery, pulmonary, 142. 
Aspirator, 117. 
Asthma, 89. 
Attributes of sound, duration, 44. 



Attributes of sound, intensity, 44. 

pitch, 44. 

quality, 44. 

rhythm, 65. 
Auricular systolic murmurs, 165. 
Auscultation, definition of, 58. 

directions for, 63. 

immediate, 58. 

in disease, 67. 

in health, 64. 

mediate, 58. 

of heart, 151. 

precautions in, 64. 
Auscultatory percussion, 53. 
Auscultatory signs, in disease, 67. 

in health, 64. 
Auxiliaries to diagnosis, 18. 
Average temperature in health, 32. 
Axillary line, 9. 
Axillary region, in phthisis, 133. 

in pleurisy, 114. 

Bacillus tuberculosis, 26. 
Binaural stethoscope, adjustment 
of, 63. 

selection of, 63. 

value of, 61. 



202 



EXPLORATION OF THE CHEST. 



Breathing, intensity of, 66. 
Bronchial breathing, 66. 

puff, 103. 
Bronchiectasis, 85. 
Bronchitis, acute, 82. 

capillary, 86. 

chronic, 84. 

croupous, 88. 
Broncho-cavernous breathing, 133. 
Broncho-vesicular breathing, 66. 
Bronchophony, 79. 
Bubbling rales, 74. 
Bulging and expansion of chest, 
22. 

Calormetatiou, 31. 
Cancer of the lung, 137. 
Capillary bronchitis, acute, 86. 
Cardiac dilatation, 179. 

hypertrophy, 176. 
Catarrhal bronchitis, acute, 82. 
Cavernous breathing, 67. 

whisper, 79. 
Chest, description of, 9. 
Chest-marks, 9. 

Cheyne-Stokes respiration, 181. 
Chronic catarrhal bronchitis, 84. 

phthisis, 126. 
Circular measurement of chest, 30. 

in emphysema, 31. 
Click, mucous, 75. 
Clubbed finger-tips, 20. 
Cog-wheel respiration, 68. 
Compensatory hypertrophy, 157, 

172. 
Coughing, bronchial breathing by, 
102. 

bronchial puff by, 103. 

friction by, 108. 



Coughing, gurgles by, 133. 

vesicular breathing by, 83. 
Corrigan's pulse, 187. 
Cosmetic pencil, 9. 
Cracked-pot sound, 48. 
Crepitant rales, 73. 
Croupous bronchitis, 88. 

Depression and retraction of chest, 

22. 
Diagnosis of diseases of lungs, 

82. 
Diastolic murmurs, 163. 
Dilatation of bronchi, 85. 

of heart, 179. 

sounds in, 153. 
Diminished breathing, 67. 
Divided respiration, 68. 
Dry pleurisy, 107. 
Dual function of the ears, 61. 
Dullness, 47. 
Duration of sound, 44. 

Emphysema, pulmonary, 93. 
Empyema or pyothorax, 116. 
Endocarditis, 170. 
Exaggerated breathing, 67. 
Expectoration of, acute bronchitis, 
25. 

cancer of lungs, 26. 

capillary bronchitis, 25. 

chronic bronchitis, 25. 

fibrous bronchitis, 26. 

haemoptysis, 25. 

oedema of lungs, 26. 

phthisis, 26. 

pneumonia, 27. 
Expiration, absence of, 66. 

prolonged, 88. 



INDEX. 



203 



Exploration of the heart, 140. 
Extraneous sounds, 77. 

Fatty degeneration of heart, 181. 
Fibroid phthisis, 135. 
Fibrinous exudation (pleurisy), 107. 
Flatness, 47. 
Friction, 76. 
fremitus, 29. 

Gangrene, pulmonary, 136. 
Gurgling rales, 75. 

Haemoptysis, 91. 
Half-circumference of chest, 30. 
Harsh breathing, 71. 
Heart, abnormal sounds of, 153. 

analysis of sounds of, 151. 

apex of, 147. 

auscultation of, 151. 

compensation of, 157. 

diagnosis of diseases of, 170. 

effect of valvular disease on, 
156. 

emphysema masking sounds of, 
153. 

flatness of, 150. 

function of, 145. 

inspection of, 146. 

mensuration of, 149. 

methods of examining, 146. 

murmurs of, 154. 

normal sounds of, 143. 

palpation of, 149. 

percussion of, 149. 

position of, 140. 

relative site of valves of, 142. 

superficial region of, 140. 

thermometry in disease of, 149. 



Heart, timing the, 152. 

vocal resonance over, 152. 
Heart-murmurs, 154. 

anaemic, 162. 

associated, 167. 

curable, 163. 

determination of, 160. 

diastolic, 163. 

dormant, 159. 

dynamical, 162. 

exceptional positions of, 164. 

genesis of, 158. 

illustration of, 155. 

possible, 159. 

presystolic, 165. 

probable, 159. 

quality of, 157. 

spurious, 159. 

systolic, 159. 

temporary tricuspid, 163. 

theory of, 155. 

transient, 171. 
Hydropericardium, 176. 
Hydrothorax, 121. 
Hypertrophy of heart, 176. 

sounds in, 153. 

compensatory, 172, 157. 

Immediate percussion, 41. 
Inspection, 18. 

of heart, 146. 
Intensity of sound, 44. 
Interlobular fissures, 12. 
Interrupted respiration, 68. 
Interstitial pneumonia, 135. 
Inspiration, 66. 
Inspiratory expansion of chest, 30. 

Key-note of resonance, 47. 



204 



EXPLORATION OF THE CHEST. 



Lobular pneumonia, 105. 
Localized depressions of chest, 23. 
Location of kidneys, 16. 

liver, 13. 

lungs, 10. 

spleen, 15. 

stomach, 14. 

Marnmillary line, 9. 

Mechanism of heart-sounds, 145. 

Mediate percussion, 41. 

Membranous casts of bronchi, 26. 

Mensuration, 30. 

Metallic tinkle, 75. 

Methods of examining the heart, 

146. 
Miliary tuberculosis, acute, 134. 
Mitral insufficiency, 191. 
Mitral stenosis, 1S7. 

with insufficiency, 189. 
Modification of heart-sounds, 153. 
Movements of thorax, in disease, 
24. 

in health, 23. 
Myoidema, 127. 

(Edema, pulmonary, 96. 

Palpation, 28. 
Parasternal line, 9. 
Pectoriloquy, 79. 
Percussion, 40. 

auscultatory, 53. 

definition of, 41. 

difficulty in, 44. 

in disease, 55. 

in health, 49. 

manipulations of, 43. 

of heart, 149. 



Percussion, positions for, 42. 

respiratory, 54. 

rules for, 44. 
Pericardial murmurs, 166. 
Pericarditis, 173. 
Phthisis pulmonalis, 125. 

acute, 125. 
Pigeon-breast, 22. 
Pitch of sound, 44. 
Pleurisy, 106. 

acute, 107. 

curvilinear flatness in, 111. 
Plexor and pleximeter, 41. 
Pneumo-hydro thorax, 121. 
Pneumonia, lobar, 98. 

lobular, 105. 
Pneumo-pyothorax, 121. 
Pneumothorax, 121. 
Position for listening to heart, 144. 
Presystolic murmurs, 165. 
Progressive valvular lesions, 172. 
Prolonged expiration, 68. 
Puerile respiration, 66. 
Pulmonary breathing, 65. 

resonance, 47. 
Purulent effusion (pleurisy), 116. 

infiltration of lung, 1 05. 
Pyothorax, 116. 

Quality of sound, 44. 



Rales, bubbling 
crepitant, 73. 
gurgling, 75. 
sibilant, 71. 
sonorous, 71. 
splashing, 75. 
subcrepitant, 73, 
tracheal, 75. 



74. 



INDEX. 



205 



Recapitulation of : 

adventitious signs, 77. 

attributes of sound, 46. 

breathing, 70. 

resonance, 57. 

rhythm, 70. 

vocal resonance, 80. 
Regional percussion in health, 48. 
Relative site of the valves, 142. 
Resistance, sense of, in percussion, 

42. 
Resonance, 46. 

modified by age, 49. 

respiration, 44. 

sex, 49. 
Respiratory percussion, 54. 

play of the lung, 51. 
Rhonchal fremitus, 29. 
Rhythm, 65. 
Rusty sputa, 27. 

Scapular line, 10. 
Senile respiration, 66. 
Serous effusion, 109. 
Sibilant breathing, 71. 
Sonorous breathing, 71. 
Sound-waves, in pneumonia, 69. 

in pleurisy, 113. 
Splashing rales, 75. 
Sputa, 25. 

Static lesions of valves, 172. 
Stethoscopes, 59. 
Subacute pleurisy, 109. 
Subcrepitant rales, 73. 
Succussion, 75. 
Summary ; signs of : 

air and fluid in pleural sac, 
124. 

asthma, 91. 



Summary ; signs of : 

bronchitis, 85. 

capillary bronchitis, 88. 

chronic phthisis, 134. 

emphysema, 96. 

oedema (pulmonary), 97. 

pneumonia, 105. 

subacute pleurisy contrasted 
with pneumonia, 120. 
Systolic murmurs, 159. 

Table of temperatures, 40. 
Temperature in: 

acute miliary tuberculosis, 38. 

asthma, 39. 

bronchitis, 36. 

cancer of lung, 39. 

emphysema, 39. 

endocarditis, 39. 

haemoptysis, 38. 

heart-disease, 39. 

hydrothorax, 39. 

oedema, 39. 

pericarditis, 39. 

phthisis, 38. 

pleurisy, 37. 

pneumonia, 37. 
Temperature, significance of, 33. 
Thermometer, manipulation of, 

34. 
Thermometry (see Calormetation), 

31. 
Thoracentesis, 117. 
Tracheal rales, 75. 
Tricuspid insufficiency, 193. 
Trocar and cannula, 118. 
Tubular breathing (see Bronchial), 

66. 
Tympanitic resonance, 48. 



206 



EXPLORATION OF THE CHEST. 



Ulcerative endocarditis, acute, 171. 

Valves of the veins, 168. 
Venous murmur or hum, 167. 

theory of, 169. 
Vesicular breathing, 65. 

resonance, 47. 



Vesiculotympanitic resonance, 48. 

in pleurisy, 112. 
Vocal fremitus, 28. 

resonance, 78. 

Water-hammer pulse, 187. 
Whispering pectoriloquy, 79. 



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SCIENCE AND PHILOSOPHY. 5 

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6 SCIENCE AND PHILOSOPHY. 

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SCIENCE AND PHILOSOPHY. 7 

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8 SCIENCE AND PHILOSOPHY. 

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SCIENCE AND PHILOSOPHY. 9 

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The Modern Applications of Electricity. By E. Ho^pitalier. New 

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Dynamo Electricitv: Its Generation, Application. Transmission, Storage, and 
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10 SCIENCE AM) PHILOSOPHY. 

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Great Ice Age, and its Relation to the Antiquity of Man. By 

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Mind in the Lower Animals in Health and Disease. By W. Lattder 
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Heredity: A Psychological Study of its Phenomena. La^vs. Causes, and Conse- 
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Suicide: An Essay in Comparative Moral Statistics. By Henry Morsf.lli. Pro- 
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The Human Species. By A. De Quatrefages. Professor of Anthropology in 
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Natural History of Man: A Course of Elementary Lectures. With an Ap- 
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Diseases of Memory : An Essay in the Positive Psychology. By Th. P.ibot. 
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12 SCIENCE AND PHILOSOPHY. 

Psychology ; or. The Science of Mind. By Rev. Oliver S. Munsell, D. D., late 
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Myth and Science. By Tito Vignoli. 12mo. Cloth, $1.50. 

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Physiological iEsthetics. By Grant Allen. 12ino. Cloth, $1.25. 

Physiology of Common Life. By George Henry Leaves. 2 vols., 12mo. 
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The Brain and its Functions. By J. Luys, Physician to the Hospice de la 
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General Physiology of Muscles and Nerves. By Dr. I. Rosenthal, 
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Life of the Greeks and Romans, described from Ancient Monuments. By 
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Antiquities of the Southern Indians, particularly of the Georgia Tribes. 
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The Dictionary of Roman and Greek Antiquities. With nearly 
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Hereditary Genius : An Inquiry into its Laws and Consequences. By Francis 
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Animal Magnetism. From the French of Alfred Beset and Charles Fere. 
12mo. Cloth, $1.50. 

PHILOSOPHY, ETC. (See also Spencer's Works.) 

Course of Modern Philosophy. By Victor Cousin. Translated by O. W. 
Wight. 2 vols., 8vo. Cloth, $4.00. 

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Moral Philosophy. By Hubbard Winslow, D. D. 12mo. Cloth. $1.30. 

Philosophy. Bv Sir William Hamilton, Bart. Arranged and edited by O. W. 
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Recent British Philosophy. By David Masson. 12mo. Cloth, $1.25. 

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English Psycholog*y. From the French of Th Eibot. 12mo. Cloth, $1.50. 



SCIENCE AND PHILOSOPHY. 13 

A History of Philosophy in Epitome. By Albert Schwegler. Trans- 
lated from the first edition of the original German by Julius H. Seelte. Ee- 
vised from the ninth German edition, containing- Important Additions and 
Modifications, with an Appendix, continuing the History in its more Prominent 
Lines of Development since the Time of Hegel, by Benjamin T. Smith. 12mo. 
Cloth, $2.00. 

EVOLUTION. (See also Works of Darwin, Huxley, Le Conte, Mivart, and Spencer.) 

Darwinism stated by Darwin himself: Characteristic Passages from the 
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The Theory of Descent and Darwinism. By Prof. Oscar Schmidt. 
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The Origin of the Fittest: ESSAYS ON EVOLUTION. By Prof. E. D. 

Cope, Member of the National Academy of Sciences. With numerous Illustra- 
tions. 8vo. Cloth, $8.00. 

Outline of the Evolution Philosophy. By Dr. M. E. Cazelles. Trans- 
lated from the French, by the Rev. O. B. Fkothingham ; with an Appendix, by 
E. L. Yoitmans, M.D. 12nio. Cloth, $1.00. 

Darwiniana. Essays and Eeviews pertaining- to Darwinism. By Asa Geay, 
Fisher Professor of Natural History iJBotany) in Harvard University. 12mo. 
Cloth, $2.00. 

Creation or Evolution ? A Philosophical Inquiry. By Geoege Ticknoe Cue- 
tis. 12mo. Cloth, $2.00. 

Our Heredity from God. Lectures on Evolution. By E. P. Powell. 12mo. 

Cloth, $1.75. 

PHYSICS. (See also Prof. Tyndall's Works.) 

Physical Optics. By R. T. Glazebeook. M. A., F. E. 8., Fellow and Lecturer 
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The Conservation of Energy, with an Appendix, treating- of the 
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Concepts and Theories of Modern Physics. By J. B. Stallo. 12mo. 

Cloth, $1.75. 

The Atomic Theory. By Ad. Wuetz, Member of the French Institute. 
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Correlation and Conservation of Forces- A Series of Expositions by 
Prof. GtEove, Prof. Helmholtz, Dr. Mayee, Dr. Faeaday, Prof. Liebig, and Dr. 

Carpentee. Edited, with an Introduction and brief Biographical Notices of the 
Chief Promoters of the New Yiews, by Prof. E. L. Youmans. 12mo. Cloth, 
$2.00. 

The Common Sense of the Exact Sciences. By the late William 
Kingdon Cliffoed. 12mo. Cloth, $1.50. 

"Elements of Physios ; or, Natural Philosophy. By Neil Aenott. Seventh 
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The New Physics. A Manual of Experimental Study for High Schools and 
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14 SCIEXCE AXD FRIZ OS PET. 

Elementary Treatise on Natural Philosophy. By A. Prtyat Descha- 
nel, formerly Professor of Physics in the Lycee Louis-le-Grand, Inspector of 
the Academy of Paris. Translated and edited, with Extensive Modifications, by 
J. D. Everett, Professor of Natural Philosophy in the Queen's College, Belfast. 
Complete in Four Parts. Illustrated by 7s3 Engravings on Wood, and Three 
Colored Plates. I. Mechanics, Hydrostatics, and Pneumatics. 8vo. Cloth, 
$1.50. II. Heat. Svo. Cloth, $1.50. III. Electricity and Magnetism. Svo. 
Cloth. $1.50. I\ r . Sound and Light. Svo. Cloth, $1.50. Complete in 1 vol., Svo, 
With Problems and Index. Cloth, $5.70. Sixth edition (revised). 

Outlines of Natural Philosophy. By J. D. Everett. P. C. L.. F. P. S., 

Professor of Natural Philosophv in the Queen's College, Belfast. Illustrated. 
12mo. Cloth, $1.00. 

Natural Philosophy for General Headers and Young- Persons. 

Translated and edited from Ganot's " Cours Elementaire de Physique, 11 by E. 
Atkinson, Ph.D., F. C. S. With Frontispiece and 40-4 Woodcuts. 12mo. 
Cloth, $3.00. 

Theory of Heat. By J. Clerk Maxwell. 16mo. Cloth, $1.50. 

Nature and Ldfe. Facts and Doctrines relating to the Constitution of Matter, 
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Cloth, $2.00. 

The Nature of Lig-ht, with a General Account of Physical Optics. 

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With 1S3 Illustrations, and a Plate of Spectra in Chromolithography. 12mo. 
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Light : A Series of Simple, Entertaining, and Inexpensive Experiments in the 
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Barnard. 12mo. Cloth, $1.00. 

Sound: A Series of Simple, Entertaining, and Inexpensive Experiments in the 
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Solar Light and Heat : The Source and the Supplv. Gravitation : with Ex- 
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Theory of Sound in its delation to Music. Bv Prof. Pif.teo Blaserna. 

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Public Debts : An Essay in the Science of Finance. By Henry C. Adams. Ph. D., 
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The Political Writing's of Eichard Ccbden. Two vols. Svo. Cloth, 
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SCIEXCE AND PHILOSOPHY. 15 

"Universal Metric System. By Aleeed Colin, C. E. 12mo. Cloth, 50 
cents. 

Money and the Mechanism cf Exchange. By W. Stanley Jevons, 
Professor of Logic and Political Economy in Owens College, Manchester. 12mo. 
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Elements of Economics. By Henry Dunning Macleod, M. A., of Trinity 
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of Exchange, Bank ]STotes, etc. Lecturer on Political Economy in the University 
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Principles of Political Economy, with some of their Applications 
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Mill's Principles of Political Economy : Abridged, with Critical, Biograph- 
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The Study of Political Economy. Hints to Students and Teachers. By J. 
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The History of Bimetallism in the United States. By J. Laurence 
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Money. By Charles Moran. 12mo. Cloth, $1.25. 

Currencv and Banking*. By Bonamy Prtce, Professor of Political Economy 
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Appletons' Cyclopaedia of Drawing". A Text-Book for the Mechanic, 
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Templeton's Engineer, Millwright, and Mechanic's Pocket Com- 
panion. Comprising Decimal Arithmetic; Tables of Square and Cube Boots; 
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Gravity, etc. Also a Series of Mathematical Tables, containing the Circumfer- 
ences, Squares, Cubes, and Areas of Circles, Superfices. and Solidity of Spheres, 
etc. Bevised, corrected, and enlarged from the eighth English edition, and 
adapted to American Practice, with the Addition of much new Matter, by Julius 
W. Adams, Engineer. lbmo. Tuck, $2.00. • 

Elements of Machine Design. By Prof. W. C. Unwin, C. E. Eevised 

and enlarged edition. 12mo. Cloth, $2.25. 

Manual of Power, for Machines, Shafts, and Belts. With a History of Cotton 
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The Strength of Materials and Structures. Part I. The Strength of 

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^Railway Appliances. A Description of Details of Eailway Construction sub- 
sequent to the Completion of the Earthworks and Structures. By J. W. Barby, 
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16 SCIENCE AND PHILOSOPHY. 

Theory of Bridge-Construction. "With Practical Illustrations. By II. 
Haupt. 8vo. Cloth, $3.50. 

A Treatise on Surveying 1 . Comprising- the Theory and the Practice. By W. 
M. Gillespie, LL. D., formerly Professor of Civil Engineering in Union College. 
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Science. With numerous Illustrations, Diagrams, and various Tables. 1 vol., 
8vo. Half leather, $3.50. 

Field-Book for Railroad Engineers. Containing- Formula? for Laying Ont 
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gether with Tables of Radii, Ordinates, Long Chords, Logarithms, Logarithmic 
and Natural Sines, Tangents, etc. By John B. Henck, A. M., Civil Engineer. 
.Revised edition. 12mo. Tuck, .$2.50. 

Strains in Trusses ; computed by Means of Diagrams, with Twenty Examples 
drawn to Scale. By Francis A. Ranken. Svo. Cloth, $2.50. 

Treatise on Handrailing 1 . By L. E. Reynolds. 20 Plates. Svo. Cloth, 
$2.00. 

The Elements of Plane Trigonometry. By Eugene L. Richards, 
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The Steam-Engine. By George C. V. Holmes. New volume of "Text- 
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Hand-Book of the Steam -Engine. A Key to the "Catechism of the 
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A Catechism of the Steam-Engine in its Various Applications in the Arts, 
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useful Rules, Tables, and Memoranda. By John Bourne, C. E. New edition, 
much enlarged, and mostly rewritten. Illustrated by 212 Woodcuts, for the most 
part new in this edition. 12mo. Cloth, $2.00. 

A History of the Growth of the Steam-Engine. By Robert H. 
Thurston, A. M.. C. E., Professor of Mechanical Engineering in the Stevens In- 
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$2.50. 

Methods for the Computation, from Diagrams, of Preliminary 
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Appletons' Cyclopaedia of Applied Mechanics. A Dictionary of 
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half morocco, $17.00. (Sold by subscription only.) 

Principles of Mechanics. By Prof. T. M. Goodeye, M. A. 16mo. Cloth, 
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A Manual of Mechanics. An Elementary Text-Book, designed for Students 
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Elements of Mechanism. By Prof. T. M. Goodeve, M. A. Revised and en- 
larged edition. lOmo. Cloth, $2.50. 

Introduction to the Physical Measurements. With Appendices on 
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from the second German edition, by T. Hutchinson Waller, B. A., and Henry 
Richardson, F. C. S. Svo. $2.50. 

MINERALOGY, ETC. 

Metals : Their Properties and Treatment. By Prof. C. L. Bloxam. With 105 
Figures on Wood. Revised edition. 12 mo. Cloth, $2.00. 



SCIENCE AND PHILOSOPHY. If 

Art of Electro-Metallurgy ; including all known of Electro-Deposition. By 
G. Goke, LL. D., F. E. 8. Illustrated. 12mo. Cloth, $2.25. 

A Treatise on Metallurgy, comprising Mining and General and Particular 
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Furnaces, Blast-Machines. Hot-Blast, Forge-Hammers, Kolling-Miils, etc. By 
Frederick Overman, Mining Engineer. With BIT Engravings on Wood. Sixth 
edition. Svo. Cloth, $5.00. 

Text-Book of Systematic Mineralogy. By Hilary Baueeman, F. G. S., 
Associate of the Koyal School of Mines, lbmo. Cloth, $2.25. 

Text-Book of Descriptive Mineralogy. By Hilary Baueeman, F. G. S., 
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History of the Conflict between Religion and Science. By Dr. John 
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The Warfare of Science. By Andrew Dickson White, LL. D., President of 
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Scientific Culture, and other Essays. By J. P. Cooke, Professor of Chemistry 
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Popular Lectures on Scientific Subjects. By H. Helmholtz. Professor 
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trations. 12mo. Cloth, $2.00. 

Popular Lectures on Scientific Subjects. By H. Helmholtz. Second 
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Students' Text-Book of Color; or. Modern Chromatics. With Applications 
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Microbes, Ferments, and Moulds. Bv E. L. Teouessaet. With 107 
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The Culture Demanded bv Modern Life. A Series of Addresses and 

Arguments on the Claims of Scientific Education. Edited, with an Introduction 

on Mental Discipline in Education, by Prof. E. L. Toumans. 12mo. CJoth, 

$2.00. ' 

Hand-Book of Household Science. By Prof. E. L. Youmans. 12mo. 
Cloth, $1.75. 

Analysis of Mr. Mill's System of Logic. By W. Stebblng, M.A. 
12mo. Cloth, $1.5J. 

History of the Inductive Sciences, from the Earliest to the Present 
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Outlines of Logic. By J. H. Gilmore, A. M., Professor of Logic, Ehetoric, and 
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Fallacies : A View of Logic from the Practical Side. Bv Alfred Sedgwick, B. A., 
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Study of Languages brought back to its True Principles. By C. 
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Life and Growth of Langnaq-e. An Outline of Linguistic Science. By 
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18 SCIENCE AND PHILOSOPHY. 

Comparative Literature. By Prof. H. M. Posn;.tt. International Scientific 
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Logic. By Prof. W. S. Jeyons. F. E. S. 

Intentional Geometry. By W. G. Spencer. 

Political Economy. By Prof. W. S. Jeyons, F. E. S. 

Natural Eesources of the United States. By J. H. Patton, M. A. 

Rational Cosmology; or, the Eternal Principles, and the Necessary Laws of 
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The Science of Law. By Prof. Sheldon Amos, M. A. 12mo. Cloth, $1.75. 



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Illustrated Encyclopaedic Medical Dictionary. Being a Dictionary of 
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First Lines of Therapeutics, as based on the Modes and the Processes of 
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Illustrated. Svo. Cloth, $4.00 ; sheep, $5.00. 

Functional Nervous Diseases: Their Causes and their Treat- 
ment. Memoir for the Concourse of 1881-1883, Academic Royale de Medecine 
de Belsique. With a Supplement, on the Anomalies of Befraction and Accom- 
modation of the Eye, and of the Ocular Muscles. By George T. Stevens, M. D., 
Ph. D., Member of the American Medical Association, of the American Ophthal- 
mological Society, etc. : formerly Professor of Ophthalmology and Physiology in 
the Albany Medical College. With 6 Photographic Piates and 12 Illustrations. 
Small Svo, 217 pages. Cloth, $2.50. 

A Treatise on the Diseases of the Nervous System. By William 
A. Hammond. M. D., Surg-eon-General U. S. Army (rerired list); Professor of Dis- 
eases of the Mind and Nervous System in the University of the CUy of New 
York, etc. Eighth edition, rewritten, enlarged, and improved. In one large Svo 
volume, with Complete Index and 112 Illustrations. Cloth, $5.00; sheep or half 
Kussia, §6.00. 

A Treatise on Insanity in its Medical Relations. By William A. 
Hammond, M.D. Svo. Cloth, $5.00; sheep, $6.00. 

Clinical Lectures on Diseases of the Nervous System. Delivered 
at the Bellevue Hospital Medical College. By William A. Hammond. M.D. 
Edited, with Notes, by T. M. B. Cross, M. D.. Assistant to the Chairs of Diseases 
of the Mind and Nervous System, etc. Cloth, $3.50. 

An Atlas of Clinical Microscopy. By Alexander Peter, M. D. Trans- 
lated and edited by Alfred C. Gieard, M. D.. Assistant Surgeon United States 
Army. Eirst American, from the manuscript of the second German edition, with 
additions. 90 Plates, with 105 Illustrations, Chromo-lithographs. Square Svo. 
Cloth, $6.00. 

The Use of the Microscope in Clinical and Pathological Exami- 
nations. By Dr. Carl Eriedlaender, Privat-Docent in Pathological Anat- 
omy at Berlin. Translated from the enlarged and improved second edition, by 
Henry C. Coe, M. D., etc. With a Chromo-lithograph. 12mo, x-195 pages. 
Cloth, $1.00. 



IMPORTANT MEDICAL BOOKS. 21 

A Treatise on the Diseases of Women. By Alexander J. C. Skene, 
M. D., Professor of Gynaecology in the Long Island College Hospital, Brooklyn, 
N. Y. ; formerly Professor of Gynaecology in the New York Post-Graduate Medi- 
cal School and Hospital, etc. One vol. Svo, 966 pages, with 254 fine Wood Engrav- 
ings and 9 Chromo-lithographs. Sold by subscription only. Extra cloth binding, 
$6.00; sheep, $7.00. 

Brain Exhaustion, with some Preliminary Considerations on 
Cerebral Dynamics. By J. Leonard Corning, M D., formerly Physician 
to the Hudson lliver State Hospital for the Insane. Crown Svo. Cloth, $2.00. 

A Manual of Midwifery. Including the Pathology of Pregnancy and the 
Puerperal State. By Dr. Care Schroeder, Professor of Midwifery and Director 
of the Lying-in Institution in the University of Erlangen. Translated from the 
third German edition by Charles H. Carter, B. A., M. D.. B. S., London, Mem- 
ber of the Eoyal College of Physicians, London, and Physician Accoucheur to St. 
George's, Hanover Square, Dispensary. With 26 Engravings on Wood. Svo. 
Cloth, $3.50; sheep, $4.50. 

Obstetric Clinic. A Practical Contribution to the Study of Obstetrics, and the 
Diseases of Women and Children. By the late George T. Elliot. M. D.. late 
Professor of Obstetrics and Diseases of Women and Children in the Bellevne 
Hospital Medical College. Svo. Cloth, $4.50. 

Practical Manual of Diseases of Women and Uterine Therapeu- 
tics, for Students and Practitioners. By H. Macnaeghton Jones, 
M. D., Examiner in Obstetrics, Boyal University of Ireland; Fellow of the Acud- 
emv of Medicine in Ireland; and of the Obstetrical Society of London. With 
1S8 Illustrations. 12mo. Cloth, $3.00. 

The Puerperal Diseases. Clinical Lectures delivered at Bellevne Hospital. 
By Fordycb Barker. M.D.. Clinical Professor of Midwifery and the Diseases of 
Women in the Bellevue Hospital Medical College; Obstetric Physician to Belle- 
vue Hospital; Honorary Fellow cf the Obstetrical Societies of London and Edin- 
burgh. Fourth edition. Svo. Cloth, $5.00; sheep, $6.00. 

The Science and Art of Midwifery. By Willtam T. Lesk, M.D., Pro- 
fessor of Obstetrics and Diseases of Women and Children in the Bellevue Hos- 
pital Medical College, Obstetric Surgeon to the Maternity and Emergency Hospi- 
tals, and Gynaecologist to the Bellevue Hospital. With 226 Illustrations. New 
edition, revised and enlarged. Svo. Cloth, $5.00; sheep, $6.00. 

A Practical Treatise on Genito- Urinary Diseases, including* 
Syohilis. By E. L, Ketes, M. D.. Professor of Genito- Urinary Surgery, 
Syphilologv, and Dermatology, in Bellevue Hospital Medical College. * A revision 
of a Treatise bearing the same title, by Tan Buren and Keyes. Second edition, 
rewritten and enlarged. With 114 Engravings. Svo, 7l4 pages. Cloth, $5.00; 
sheep, $6.00. 

Diseases of the Ovaries : Their Diagnosis and Treatment. By T. Spencer 
Wells, Fellow and Member of Council of the Boyal College of Surgeons of Eng- 
land, etc. Illustrated. Cloth, $4.50. 

Pyuria ; or, Pus in the Urine, and its Treatment : Comprising the 
Diagnosis and Treatment of Acute and Chronic Urethritis, Prostatitis. Cystitis, 
and Pyelitis, with especial reference to their Local Treatment. By Dr. Eobert 
Ultzmann, Professor of Genito-Urinary Diseases in the Vienna Poliklinik. 
Translated, by permission, by Dr. Walter B. Plait, F. E. C. S. (Eng.), Balti- 
more. 12mo. Cloth, $1.00. 

Syphilis and Marriaare. Lectures delivered at the St Louis Hospital. Paris. 
By Alfred Foeknier, Professeura la Faculte de Medecine de Paris; Medecin de 
THopital Saint-Louis; Membre de TAcademie de Medecine. Translated by P. 
Albert Morrow, M. D., Physician to the Skin and Venereal Department, New 
York Dispensarv; Member New York Dermatological Society; Member New 
York Academy of Medicine. Svo. Cloth, $2.00; sheep, $3.00. 



22 IMPORTANT MEDICAL BOOKS. 

The Tonic Treatment of Syphilis. By E. L. Keyes, A. M., M. D., Adjunct 
Professor of Surgery and Professor of Dermatology in the Bellevue Hospital 
Medical College, etc. Svo. Cloth, $1.00. 

The Pathology and Treatment of Syphilis and Allied Venereal 
Diseases. By Hermann von Zeissl, M.D. Second edition, revised by 
Maximilian yon Zeissl, M. D. Translated, with Notes, bv H. Raphael, M. I). 
8vo. Cloth, $4.00; sheep, $5.00. 

A Practical Treatise on Tumors of the Mammary Gland: em- 
bracing their Histology, Pathology, Diagnosis, and Treatment. By Samuel W. 
Gross, A. M., M.D., Surgeon to, and Lecturer on Clinical Surgery in. the Jefferson 
Medical College Hospital and the Philadelphia Hospital, etc. in one handsome 
8vo volume. With 29 Illustrations. Cloth, $2.50. 

Analysis of the Urine. With Special Eeference to the Diseases of the Genito- 
urinary Organs. By M. B. Hoffman, Professor in the University of Gratz, and 
R. Ultzmann, Docent in the University of Vienna. Translated from the German 
edition under the special supervision of Dr. Ultzmann. By T. Barton BrUne, 
A.M., M.D, Eesident Physician Maryland University Hospital, and H. Hol- 
bro ok Curtis. Ph. B. With 8 Lithographic Colored Plates from Ultzmann and 
Hoffman's Atlas, and from Photographs furnished by Dr. Ultzmann. -which do not 
appear in the German edition or any other translation. Second edition, revised 
and enlarged. Svo. Cloth, $2.00. 

Manual of Chemical Examination of the Urine in Disease. With 

Brief Directions tor the Examination of the most Common Varieties of Urinary 
Calculi, and an Appendix containing a Diet-Table for Diabetics. By Austin 
Flint, Jr., M. D. Sixth edition, revised and corrected. l2mo. Cloth, $1.00. 

Lectures on the Principles of Surgery, Delivered at Bellevue Hospital. 
By the late W. H. Van Buren, M. D. Edited by Lewis A. Stimson, M. D. Svo, 
iv-5SS pages. Cloth, $4.00; sheep, $5.00. 

Lectures upon Diseases of the Rectum and the Surgery of the 
Lower Bowel. Delivered at the Bellevue Hospital Medical College. By 
W. H. Van Buren, A. M., M. D., Professor of the Principles and Practice of Sur- 
gery in the Bellevue Hospital Aledical College, etc. Second edition, revised and 
enlarged. Svo. With 2T illustrations and complete Index. Cloth, $3.00; sheep, 
$4.00. 

On the Bile, Jaundice, and Bilious Diseases. By J. Wickham Lego, 
M.D., P. K. C. to., Assistant Physician to St. Bartholomew's Hospital, and Lect- 
urer on Patho.ogical Anatomy in the Medical School. W T ith Illustrations in 
Chromo-lithography. Svo. Cloth, $6.00 ; sheep, $7.00. 

!3and-Book of Skin Diseases. By Dr. Ibidor Neumann, Lecturer on Skin 
Diseases in the Royal University of Vienna. Translated from the German, second 
edition, with Note's, by Lucius D. Bulkley, A.M., M.D., Surgeon to the New 
York Dispensary, Department of Venereal and Skin Diseases; Assistant to the 
Skin Clinic of the College of Physicians and Surgeons, New York; Member of 
the New York Dermatological Society, etc. 66 Woodcuts. Svo. Cloth, $4.C0; 
siieep, $5.00. 

A Practical Treatise on Diseases of the Skin. By John Y. Shoe- 
maker, A. M., M. D., Professor of Dermatology in the Medico-Chirurgical College 
of Philadelphia. With 6 Chromo-lithographs and numerous Engravings. Svo. 
Cloth, $o.00; sheep, $6.00. 

Manual of T ermatolog-y . By A. R. Robinson, M. R. L. R. 0. P. and S. (Edin- 
burgh). Revised and corrected. Svo, 647 pages. Cloth, $5.00. 

A Practical Treatise on the Diseases of Children. By Alfred Vogfl, 
M. D., Professor of Clinical Medicine in the University of Dorpat. Russia. Trans- 
lated and edited by H. Raphael, M. D., formerly House Surgeon to Bellevue 
Hospital. Third American from the eighth German edition, revised and enlarged. 
Illustrated by 6 Lithographic Plates. 1 vol., Svo, xii-640 pages. Cloth, &4.50; 
sheep, $5.50. 



IMPORTANT MEDICAL BOOKS. 23 

Compendium of Children's Diseases. A Hand-Book for Practitioners and 
Students. By Dr. Johann Stein eh. Protessor of the Diseases of Children in the 
University of Prague, and Physician to the Prancis-Joseph Hospital for Sick Chil- 
dren. Translated from the second German edition by Lawsox Tatt. P. R. C. 8., 
Surgeon to the Birmingham Hospital for l\"omeii ; Consulting Surgeon to the 
West Biomwich Hospital, etc ^vo. Cloth, $3.50; sheep, $4.ou. 

General Surgical Pathology and Therapeutics, in Pifty-one Lectures. 
A Text -Book for Students and Physicians. By Dr. Theodok Billroth. Protessor 
of Surgery in Vienna. Translated by Chato.es B. Hackley. A M., M. D.. Physi- 
cian to^the New York Hospital; Fellow of the New York Academy of Medicine. 
Bvo. Cloth, $5.00; Bheep, $6.00. 

A Manual of Operative Surgery. By Joseph D. Betaxt. M. D. . Professor 
of Anatomy and Clinical Surgery, and Associate Professor of Orthopaedic Surgery 
in Bellevue* Hospital Medical College ; Visiting Surgeon to Bellevue Hospital, and 
Consulting Surgeon to the New York Lunatic Asylum and the Out-Door Depart- 
ment of Bellevne Hospital. New edition, revised and enlarged. \Yith 793 illus- 
trations. 8vo, 530 pages. Cloth, $5.00; sheep, $6.0u. 

A Text-Book on Surg-ery: General Operative, and Mechanical. By John A. 
TVteth. M. D.. Professor of Surgery in the New York Polyclinic: Surgeon to 
Mount Sinai Hospital, etc. With 771 Illustrations, about 50 of them colored. Svo. 
Sold by subscription only. Buckram, uncut edges, $7.0u; sheep, $8.00; half 
morocco, $3.50. 

The Rules of Aseptic and Antiseptic Surg-ery. A Practical Treatise 
for the Use of Students and the General Practitioner. By Aepad G. C-eestee. 
M. D.. Professor of Surgery at the New York Polyclinic : A isiting Surgeon to the 
German Hospital and to Mount Sinai Hospital, New York. Illustrated with over 
200 Pine Engravings. Svo. Cloth, $5.00 ; sheep, $6.00. 

Operative Surgery on the Cadaver. By Jaspbu Jkwutt Garmany, A. Iff., 

M. D.. P. P^ 0. S.. Attending Surgeon to Out-Door Poor Dispensary of Bellevue 
Hospital; Visiting Surgeon to Ninety -ninth Street Reception Hospital: Member 
of the British Medical Association, etc. With 2 Colored Diagrams showing the 
Collateral Circulation after Ligatures of Arteries of Arm, Abdomen, and Lower 
Extremity. Small Svo. 150 pages. Cloth, $2.00. 

A Treatise on Oral Deformities, as a Branch of Mechanical Surgery. By 

Norman W. Kingslbt, M. D. S . D. D. S., President of the Board of Censors of 
the State of New York, late Dean of the Xe^v York Col ; ege of Dentistry and 
Professor of Dental Art and Mechanism. Member of the American Academy of 
Dental Science, etc. With over 350 Illustrations. Svo. Cloth. $5.00; sheep, 
$6.00. 

Contributions to Reparative Surg-ery, showirer its Application to the 
Treatment of Deformities, produced by Destructive Disease or Injury; Con- 
genital Defects from Arrest or Excess of Development; and Cicatricial Contrac- 
tions following Bums. Illustrated by 30 Cases and fine Engravings. Bv Gcedon 
Buck, M. D. "Svo. Clot'.), $3.00. 

Diagnosis and Treatment of diseases of the Far. By O. D. Pombkoy, 

M. D.. Surgeon to the Manhattan Eye and Ear Hospital, etc. With 100 Illustra- 
tions. Xew edition, revised and enlarged. Svo. Cloth, $3.00. 

A Eand-Boo\ of the Diseases of the Eye and the'r Treatment. 
By Hbnby R. Bwabzy, A. M.. M. B.. P.P. C. S. I . Surgeon of the National Eye 

and Ear Infirmary, formerly, assistant, to the late Professor A. von Graefe, Berlin. 
\Yith. Illustrations. l2mo. xv-437 pages. Cloth, $3.00. 

A Tex f -Book of Ophthalmoscopy. By Edward G. Losing. M. D. Part 
I — The Normal Eye. Determination of Refraction and Diseases of the Media, 
Physiological Optics, and Theory of the Ophthalmoscope. Svo. 267 pages. With 
131 Illustrations, and ■£ Chromo-lithograph Plates, containing 14 Figures. Cloth, 
$5.00. 



24 IMPORTANT MEDICAL BOOKS. 

Diseases of the Heart and Thoracic Aorta. By Byron Bkamwell, 
M. I)., F. R. C. P. E., Lecturer on the Principles aud Practice of Medicine, and on 
Practical Medicine and Medical Diagnosis, in the Extra-Academical School of 
Medicine, Edinburgh, etc., etc. With 226 Wood Engravings and 68 Lithograph 
Plates, showing 91 Figures— in all 317 Illustrations. &vo, 763 pages. Cloth, $8.00 ; 
sheep, $9.00. 

A Treatise on Diseases of the Bones By Thomas M. Markoe, M. D,, 
Professor of Surgery in the College of Physicians and Surgeons, New York, etc. 
With numerous Illustrations. 8vo. Cloth, $4.50. 

Medical and Surgical Aspects of In-Knee (Genu -Valgum): Its Eela- 
tion to Rickets; its Prevention; and its Treatment, with or without Surgical 
Operation. By W.J. Little, M. D., F. K. C. P., late Senior Physician to and Lect- 
urer on Medicine at the London Hospital; Visiting Physician to the Infant Or- 
phan Asylum at Wanstead; the Earlswood Asylum for Idiots; Founder of the 
Eoyal Orthopaedic Hospital, etc. Assisted by E. Mutehead Little, M. B. C. S. 
One 8vo volume, contaiaing 161 pages, with complete Index, and illustrated by 
upward of 50 Figures and Diagrams. $2.00. 

Lectures on Orthopedic Surgery and Diseases of the Joints. De- 
livered at Bellevue Hospital Medical College during the Winter Session of 1874- 
'75. By Lewis A. Sayre, M. D., Professor of Orthopedic Surgery, Fractures and 
Dislocations, and Clinical Surgery, in Bellevue Hospital Medical College, etc. 
With 324 Engravings on Wood. "Second edition, revised and greatly enlarged. 
Svo. Cloth, $5.00; sheep, $6.00. 

Osteotomy and Osteoclasia for Deformities of the "Lower Ex- 
tremities. By Chaeles T. Pooee, M.D., Surgeon to St. Mary's Free Hospital 
for Children, New York; Member of the New York Surgical Society, etc. bvo, 
202 pages. With Illustrations. Cloth, $2.50. 

A Practical Manual on the Treatment of Club-Foot. By Lewis A. 
Sayee, M. D. Fourth edition, enlarged and corrected. Illustrated. 12mo. Cloth, 
$1.25. 

The Comparative Anatomy of the Domesticated Animals. By A. 

Chaltveatj. Professor at the Lyons Veterinary School. New edition, revised and 
enlarged, with the Co-operation of S. Arloing, late Principal of Anatomy at the 
Lyons Veterinary School. Translated and edited by James Fleming-. With 450 
Illustrations. Svo. Cloth, $0.00. 

Emergencies, and How to Treat them. The Etiology, Pathology, and 
Treatment of Accidents, Diseases, and Cases of Poisoning, which demand Prompt 
Action. Designed for Students and Practitioners of Medicme. By JosErH W. 
Howe, M. D, Clinical Professor of Surgery in the Medical Department of the 
University of New York, etc. Third edition. 8vo. Cloth, $2.50. 

Hand-Book of Historical and Geographical Phthisiolog-y, with 
Special Preference to the Distribution of Consumption in the United States. By 
Geoege A. Evans, M.D. 12mo. Cloth, $2.00. 

On the Treatment of Pulmonarv Con^nmotion, "by Hygiene, Climate, 
and Medicine, in its Connection with Modern Doctrines. By James Henky Ben- 
net, M. D. Svo. Cloth, $1.50. 

Exploration of the Chest in Health and Disease. By Stephen 
Smith Burt, M. D.. Professor of Clinical Medicine, etc., in the New York Post- 
Graduate Medical School and Hospital, etc. 12mo. 

The Curability and Treatment of Pulmonary Phthisis. By S. Jac- 
coud. Professor of Medical Pathology to the Faculty of Paris. Translated and 
edited by Montagu Lubbock. M. D. (London and Paris), M. K. C. P. (England), 
etc. 8vo, 40T pages. Cloth, $4.00. 



New York: D. APPLETON & CO., Publishers, 1, 3, & 5 Bond Street. 




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